When I was 11 years old in 1989, my mother brought me to an orthodontist at the referral of our dentist, because he thought I had an over-bite.
My mother and I had the initial consultation with the orthodontist, and in that meeting, he told me that I had an overbite and crowding in my upper teeth. He said that my upper jaw had grown too far forward, and that he needed to restrict its growth so that the lower jaw could catch up. He said that I needed cervical headgear or extractions, headgear being the better option. He also told me that not only would the headgear allow my lower jaw to catch up to my upper jaw, but that it would create room for my crowded upper arch by pulling teeth back. I asked him if there were any alternatives to headgear and he said there were none. I asked him if there were any side-effects to headgear, and he said there were none, except that in extremely rare cases, the lower jaw continues to grow forward uncontrollably and that the remedy for this is a quick surgery where we cut a nerve under the neck at the side of the jaw, which stops the forward growth.
As a child, I never had trouble sleeping or waking up. I always ate breakfast with my family in the mornings, and had time to do things that a kid did, like watch cartoons, or run around and play while my mom made us breakfast. The short version of the story is that a few months after wearing headgear, those morning rituals gradually faded away and were replaced with the struggle of waking up more fatigued than when I went to bed. Fatigue eventually mapped out a large portion of my life, and it was something that I battled with on a daily basis. Finally, in March of 2013, at the age of 35, I was diagnosed with moderate to severe obstructive sleep apnea. The cause: A maxilla and mandible that had not grown forward enough, causing an upper airway obstruction.
I have since learned that by 1989, many orthodontists had stopped using cervical headgear due what studies call "disastrous" side effects on craniofacial growth, namely a backwardly grown or underdeveloped maxilla and mandible causing a flattened and vertically grown face, and that these abnormal effects were not yet understood at the time. The side effects have been published in peer-reviewed journals countless times since the 1950’s. I have also learned that since the early 1900’s, orthodontists, otolaryngologists and other doctors have identified an underdeveloped maxilla as being a major cause of upper airway obstruction, which, according the literature, wreaks havoc on a person’s health. The part that baffles me the most, is that orthodontists have identified that without orthodontic treatment, a child’s face tends to grow more forward than with treatment, and in untreated cases, the lower jaw tends to catch up to the upper jaw during adolescence.
After reading the research, I had no doubt that headgear can cause sleep apnea. And I am not alone in that conclusion. Between 1999 and 2012, there have been at least six peer-reviewed, published studies done which state that cervical headgear impacts the patency of the airway, that it reduces the volume of the airway, that it puts a patient at risk for obstructive sleep apnea, and that it has been clinically observed to cause sleep apnea in children while they wear it.
Despite the published evidence to the contrary, there are orthodontists today who still restrict natural growth using cervical headgear or other means, also without disclosure of the known risks to their patients. I believe this is unacceptable and needs to stop.
If you’re interested in learning about the consequences that growth restriction of the airway by way of hindering the growth of the upper jaw can have on a person’s life, I invite you to read on. I've also included some before and after pictures at the end of this write up so that you can understand the types of growth changes that the public has allowed the orthodontic industry to get away with.
As I mentioned, at the age of 11, things changed when I started to wear headgear. I started waking up fatigued on a daily basis, literally within months of wearing the headgear but never in my wildest dreams as a kid did I connect the two. The fatigue crept up on me gradually enough such that I could never notice that something was drastically wrong. As I started to wake up tired, I also started to wake up later too. Gone were the days of eating breakfast with the family. I would be out of bed long after breakfast was made and I’d be in a rush getting ready for school while my mom and my little sister were in the car, waiting for me and late for their destinations. Since then, I became known as the person who made everybody late. At the age of 11, my mornings had become rushed and this is something that would never change for 25 years. I’d eat breakfast in the car as fast as I could, and on many days, I’d be so late in the morning that I washed my face at school.
As the years went by, my fatigue increased and coping with it had become a way of life for me. I learned to sleep in almost any situation, and to take almost any opportunity to close my eyes and nap. I learned how to take tiny 30 second naps to get me through the next 15 minutes if I was particularly tired, and I could even do this while playing sports. Sports became a particular challenge for me because I never thought I was any more or less fatigued than other kids, which made me wonder why keeping up with them put me in so much physical distress, and why I’d be out of breath so fast. When my braces came off, I was put in a fixed upper and lower retainer designed to limit the effects of natural lateral growth during my growth spurt years, and my fatigue became worse. In my final year of high school, I napped during almost every recess in the school nurse’s room because it had a bed, and I napped during most of every lunch break. On rare occasions, I was so tired that I slept through the entire lunch break without eating and on those days, concentrating in some afternoon classes became a challenge because I was hungry, but it beat being exhausted from a lack of sleep which caused my body to twitch in fatigue if I waited too long before taking a nap. Having a social life for me was not much of an option. I had to work twice as hard as most kids to maintain my grades, and at night on the weekends while other kids were partying, I needed to sleep.
Fatigue followed me everywhere. College was a particular challenge, as after doing my best to listen intently to a professor, I would find myself being woken up by the student next to me at the beginning of the next lecture. I would go to the library to study, and after twenty minutes of reading, I would always need to take a short nap. I cannot count how many times I have woken up from those short naps, only to realize that I had been asleep for hours. However, I managed to finish an engineering degree with dreams of one day starting a desalination company.
After college I started to work, and again, fatigue followed me there. The issue with work is that I had to be on time at a desk, the entire day, and there was no nurse’s room to get me through the morning, so finding places to nap became quite a challenge. Finding time to eat also became a challenge because if I had any break, lunch included, I would use it to sleep, otherwise, I could not function. It was always a choice between fatigue or hunger. Fatigue usually won the battle, and I would skip breakfast or lunch to get that extra sleep. Hunger, however, can be as debilitating as fatigue. Sometimes one can feel like the other, and I maintained a constant balancing act between the two. If I could, I used to eat in work meetings. I carried food with me everywhere I went, eating small amounts here and there during work, doing the best I could to have energy. I was like a car with only enough gas to go the next half mile, where I had to refill, and could only refill enough for another half mile. If I could summarize a typical day for me, it looked like this: Micro nap, bite of food, work for twenty minutes, micro nap, micro nap, too much pain, twitching from fatigue is starting and head is starting to fall, go the bathroom and sleep while I pretend to be sick, pain lessened, work for an hour, sleep at lunch time, back to work, stomach is starving, eat a little bit, work twenty minutes, in pain again and need micro nap, need food, in pain from hunger, work for twenty minutes, too hungry to concentrate, eat a little bit on the way to a meeting, close my eyes for five seconds while the person I’m meeting with looks away, stomach is hurting during meeting but cannot eat in this meeting, meeting is finally over and I couldn’t even think about what was being said but did a good job pretending, go to the bathroom and eat there, back to work. And the day was done.
After work, the first thing I would do is go home, eat a meal right away while exhausted and then sleep for an hour. The sleep would get rid of my headache and stabbing pain in my eyes, and the fact that I had eaten an hour ago allowed me to have my workout without a full stomach. After my one hour nap, nearly every day, I forced myself to go for a run or do some type of workout. My father was an athlete – a distance runner – and my mother, a health nut who raised us on a very healthy diet, came from a family of sportsmen so the importance of being in healthy physical shape was instilled in me as a child. So I ran, and if I could sum up the effects of running in one word, it would be “depression.” My parents would always tell me about the “runner’s high” and how happy running used to make them, and I never understood it. Running and exercise in general depressed me. However, I still ran and worked out regularly, in addition to keeping a healthy diet, because not only did those values from my childhood never leave me, but I also found that running, if done in the right amount and at the right time, helped me to fall asleep faster. After my run, it would be 8pm and that’s when I’d have my dinner. By 9pm the dishes were done and I had an hour or two in my day to buy groceries, meet a friend, run any errands I needed to run, make any phone calls I needed to make, prepare food for the next day, shower, do some reading and be in bed. I tried my best to make 11pm my curfew. If I didn’t touch my pillow by around 11pm, it made a huge difference in my fatigue the next day. There was no time for television, no time for extended socializing, because if anything interfered with me getting enough sleep, enough food and my workout, there was no room for it.
The next day, I’d wake up in the morning at 8am or as early as I could, ritualistically more fatigued than when I went to bed, and as usual, there would be no time for breakfast. I’d put my clothes on as fast as I could with my eyes closed, grab my razor so that I could be on time at work and shave there in a bathroom on another floor, grab my pre-packed breakfast, run as fast as I could to catch the bus and grab a few bites on the way, button up my shirt while on the bus, do my tie on the bus, tuck my shirt in, do up my belt with people oddly watching, eat a few bites of my breakfast and save the rest for later because I had to be at work on time. I also learned to eat and run at the same time. If I was running to catch the bus to work, that was an opportunity to eat. If I had any spare still time on the bus after getting ready, that was my time to close my eyes. If I was late for anything in the morning, it was always because I was struggling to get more sleep and if I could scrounge an extra minute or two in the morning for a little more sleep, I would. That was my formula. And it rarely worked. I have been fired from almost every job I have ever had. Bosses and colleagues wondered why I would come to work late, why I was always nibbling, why I spent so much time in the bathroom, why I made so many mistakes, why simple things would take me so long, and in all fairness to them, why they hired me.
Maintaining a career and earning an income were probably the most difficult parts of living with sleep apnea. As entrepreneurial and motivated as one can be , careers and businesses cannot thrive when a person cannot breathe. My first job out of college was in California working for a residential designer as a engineering draftsman. I lost that job after less than a year due to fatigue at work. My next job was working as an engineering technologist for a buildings assessment company and after six weeks, I was let go for fatigue again. This was a reflection of all the summer jobs and internships I took while in school, in which I could never be both alert and on time; it was one or the other and rarely either. After losing the technologist job, I remembered the fatigue throughout all of those summer jobs and internships I had and I lost faith in being able to have a career. With enough money in my pocket for one month's rent and some groceries, I managed to find a job working for an apartment building owner who needed somebody to help him coordinate maintenance and keep his database updated. He wanted somebody with ten years of experience but I was desperate so I offered to work for him for far less than what it would have cost him to have that ten-year individual, and I got the job. It was only for four hours per day and it was almost enough to pay the bills. My day there would start at 9am and would end at 1pm. From 2pm to 4pm I would nap, and at nights, I telemarketed on commission. That is how I paid my rent and survived from 2002 to 2005
In 2006, I decided to go back to school and do a master's in engineering at McMaster University in Hamilton, Ontario. Because my courses were in the evening, I was able to excel. I was the top student in my class and in 2007, I met a professor who had a patent-pending desalination technology that I believed could solve a part of the world's water crisis. He was looking to take to market and I instantly jumped on it. I found an investor who agreed to fund the initial prototyping, and in the afternoons before class, I would cold call industrial water users who could potentially demo the technology in order to prove it out. By the time I graduated, I had list of customers, an investor and my dream of a desalination company was close to coming true. My investor offered me a job and a small partnership stake in his venture fund while we worked on the desalination business and foolishly, I took the job. The comute was half an hour by car and having to give up that amount of sleep was a sacrifice that I ultimately could not afford to pay. Not once was I at work on time, and I need both hands to count the number times per day I would go the bathroom pretending to be sick in order to sleep. Although I believe I performed my job well, managers would notice me coming to work late and I could never sneak in because of the position of my desk relative to theirs. Relations at work soured with my co-workers due my lateness, people wondered why I spent so much time in the bathroom, and this dried my investor's confidence in working with me. In the summer of 2008, after investing two years into this new venture, the investment in the desalination company was halted. Dejected and not knowing how I would earn a living, I decided to move back home to my parents house in Vancouver. I also vowed never to live more than a few minutes away from a place of work. Nonetheless, given that my investor's office was in an industrial park, I didn't have much choice in the matter.
In Vancouver at the suggestion of my mom, I started tutoring in the evenings and did this from 2009 to 2011. I excelled at this job because I could sleep as much as I needed and work in the evenings. Out of over 1000 tutors in my agency, many of which were licensed teachers, in 2010 I won the teacher-of-the-year award. During the daytime, for the the three years between 2009 and 2011 I tried to revive the desalination company while volunteer for a housing non-profit I was starting but I would always crash and burn with fatigue. After three years of tutoring, I ended up working as a consultant for the father of one my students who greatly appreciated how I helped his son learn French. He was a real estate developer who I had approached to fund a non-profit housing project. Although he declined the project, he offered to hire me as a consultant on a few of his own projects. At that time, I did not know I had sleep apnea and although I feared that I would get fired from not being alert or on time, I took the job. Anytime I had a day job, I always knew that the rainy day, and days, were on their way. One or two important morning meetings missed because I didn't wake up, and I was out the door. So, I learned to save my money while I earned, and to live well below my means. As a result, and to this day, I have not had more than a few hundred dollars of consumer credit card debt, and never more consumer debt than cash in the bank, and regardless of what the future holds, I'll probably maintain that habit.
Despite some valuable habits I learned, fatigue, over the past two and half decades, has been my greatest rival. During that time, I have taken naps in almost every type of location and during almost any activity or event imaginable. I’ve slept in rock concerts, in lecture halls, during exams, while playing soccer, on the job, during a conversation, on a date, on the bus, in public washrooms, while jogging, under my desk, on my desk, while on hold over the phone, during breakfast, while showering, while brushing my teeth, while shaving. The list goes on. I never knew that I might have a tangible health problem. I simply wondered why everybody else could wake up refreshed, keep a job, and be chipper with time for breakfast and morning activities. I always thought they were just as tired as me, and simply had a better mind to cope with it.
My fatigue was paired with constant depression. Not being able to participate in normal activities, pretending to be awake to maintain politeness and a job, constantly fighting off fatigue and hunger throughout an entire day along with the physical pain and twitching that came alongside took a toll on me personally. So, when clinicians talk about the correlation between sleep apnea and depression, I know first hand exactly what they are talking about.
I also feared going to sleep. Over the years, albeit rare, I have had nightmares of choking. More than sleep itself, I dreaded the fatigue that sleep would bring the next day, and the physical pains of waking up more exhausted than I was before I went to bed. I found myself waking up several times a night, panting, sometimes sweating and never knew why. Ironically, sleep became something I did my best to avoid, tried my best to have, and fatigue paired with hunger were my constant enemies. It was a vicious three-dimensional cycle that I knew no way to end. I thought all of this was normal and never told anybody, because it started when I was so young.
While tutoring in 2010, some sudden changes in my sleep patterns started that alarmed me. Several nights in a row, while on my side, the feeling of a bead of sweat falling from one arm onto another would wake me up, and I'd try to wipe it off my arm thinking it was just a drop, but my entire hand would end up covered in sweat and I'd wake up only to realize that these were not just beads of sweat, but that my entire body was soaked. I was so drenched, it was as though I had gone for a swim. My pajamas, my bed sheet, my blanket and pillow seemed as though somebody had poured a bucket of water on them. I became concerned that I was losing electrolytes very quickly and I was sluggish, to say the least, if I tried to go for a run or do any type of exercise during the day. I had experienced night sweats in the past, but never to this intensity and they were rare. Now, although unpredictable, they were often and I could not avoid them. So I went and saw my doctor to discuss this and my sleep, and was referred to a sleep specialist in Burnaby. He put me on an overnight oximetry test and made the conclusion that I was simply restless. The following year, I started to gain weight rapidly, and no matter how much or how hard I worked out, I had developed a gut. I went back to my doctor who ordered blood tests, which came back normal. I still knew something wasn't right, and thought that perhaps it was dietary, even though I was eating a very healthy diet. So I brought my diet down to a bare bones menu, eating only the most basic foods, cutting out anything that had been the slightest bit refined. My weight did come under control, and by what I think is a stroke of luck, the night sweats diminished greatly. Today, I wonder whether sleep apnea impacts digestion, and given its mechanics, I'm sure it would. However, the next three years were plagued with constant colds, what seemed like incomplete digestion and an overall inability to stay healthy.
Then, in January of 2013, in one night, my fatigue grew by orders magnitude. I woke up one morning so exhausted that I literally did not have enough energy to get out of bed. That morning, I felt as though I was velcroed to my mattress with limbs heavier than I had ever experienced. I felt as though I had not slept for days. I was dizzy and my vision was blurred. I had the sharpest shooting pains in my eyes and head I had experienced thus far and this continued for several days. I told my older sister about this – who was studying to become an naturopathic doctor (ND) – and she said to me that this sounded like sleep apnea and told me to see a doctor. I went to a walk-in clinic in New Westminster where I was seen by the first doctor available. He, too, suggested that I may have sleep apnea and recommended an overnight oximetry test. I took the test at home on January 17, 2013, which, although not conclusive, indicated that I may have severe sleep apnea. I then booked an appointment with my regular physician, who referred me to a respirologist, who sent me for an overnight polysomnography (PSG) at Surrey Memorial Hospital, which was taken in March of 2013. The results of my PSG showed that I had moderate to severe sleep apnea, and the doctor who interpreted the results stated that he suspected my sleep apnea to be more severe than the PSG indicated. It turned out that I stopped breathing 23 times per hour in my first stage of sleep, and 76 times per hour during REM. Each time I stopped breathing, the doctor explained, my oxygen levels dropped and that this would cause my body to wake up without me knowing. He said that as a result of waking up so many times during the night, I never really got much rest, which explained my constant fatigue. I then went to see an ear, nose and throat doctor about options to treat my sleep apnea. He put a camera down my nose and throat, and told me that my airway was one quarter the size it should be, which explained that my sleep apnea was caused by an upper airway obstruction. He indicated that due to the severity of my upper airway restriction, than an oral appliance would likely be ineffective. I was given surgical options and was told to get on a CPAP machine. I took a second opinion from another ear, nose and throat doctor, and he told me the same thing that the first one did. He also noted that both my upper and lower jaws were positioned too far back than normal, and that this interfered with my airway. Two oral surgeons I saw and two dentists told me the same thing, “Omar, your maxilla is pushed too far back. It is trapping your mandible from coming forward and both your jaws need to come forward to expand your airway.” 25 years ago, in 1990, a backwardly positioned upper and lower jaw were well-known and well-documented side effects of cervical headgear. The enclosed pictures of me as a child before headgear do not exhibit these traits.
I have been on CPAP therapy for nearly two years now, and I can honestly say, up until January of 2015, these have been the best two years of my life. Instead of being fatigued and starving all day long at work, every day of the week, this only happened two to three days a week. I also told bosses, clients and colleagues about my sleep apnea, and that if I came to work late, it is because I needed the sleep. They understand and I simply work longer hours to get my work done. And, thanks to CPAP, I've been able to earn a living working as a consultant for five years in a row for the same father of the son I who I taught French in 2010.
CPAP therapy had literally changed my life and I am eternally grateful to its inventor. Getting used to a CPAP machine was not easy, and I didn’t tolerate the machine for the first six months. At certain pressures, CPAP leaves it’s user with an extremely dry mouth, so dry in fact that the inner cheeks become stuck to the gums and have to be peeled off during the night, or sometimes it leaves the user with the feeling of being punched in the nose and it has to come off. Nonetheless, my life had changed for nearly two years after I found CPAP and it became my best friend for a time. I also learned to tape my mouth shut while I sleep, and the Sahara-like dry mouths became a thing of the past. At times during that period, I would wake up to find my CPAP mask mysteriously sitting beside me, and on those days, I knew I had to face fatigue because I didn’t get the oxygen I needed. But it only happened once in a while and I had no major problems up until January of 2015.
I started the 2015 New Year having just recovered from a cold that started in mid-December. (Having a cold that lasts two to three weeks, I've recently learned, is normal for someone with obstructive sleep apnea.) I was looking forward to a new year at work, having kept a job nearly four years in a row. The problem with CPAP is that it drives an unnaturally high velocity of air down the throat, and over those two years, my airway had become narrower. My doctor doesn’t know the reason for this, however, a dentist who specializes in sleep apnea suggested that muscles in the throat may grow larger due the counter pressure they exert against the CPAP’s inflow air pressure, and that this could explain my further narrowed airway, that my overgrown muscular tissues in my throat were crowding my already narrow airway. From January of 2015, up until the beginning of April of 2015, my health went into rapid decline and CPAP stopped having its positive effect on me. At times, air would go down my stomach or would shoot out of my mouth, and would go anywhere but through my airway. I again started to wake up fatigued, and this time, the fatigue was more painful and debilitating than I had ever experienced prior. I would wake up with headaches that felt as though a worm with a scalpel on its head was crawling through my brain and eyes. I had to sleep 11 to 12 hours a day to be barely functional, and during those months, I would still need one or two hour long naps each day. My productivity at work dropped greatly, and as each week went by, the pain got worse. If I went for a run, I could barely do it and I would be sore for over a week. The pain from my fatigue became so bad one day that I went to the emergency room at St. Paul’s Hospital on the way home from work, because I had so much pain in my head and eyes, and I couldn’t walk in a straight line. There was no conclusion at the hospital, however, my vision became blurrier by the day and in the kitchen at work one day, I tried to open a cabinet door and missed the handle. I became extremely worried and the decline was rapid. I lost hope when I realized that in order to have enough time to keep a job, I had no energy or time in my day to look for ways to help myself. I feared going back to the days of not having an income. In my 20s, it was somewhat acceptable because I could always live with my parents, however, in my mid-30s, I didn’t feel this was an option. I had little time to see doctors, because it took time away from my already compromised work, and when I did find time to see one, there were no conclusions or answers. I tried to increase the pressure on my CPAP machine, but the fatigue was getting worse and worse, and in the downward decline I began to fear for my life. I was living a nightmare and I knew no way to make it stop. By that point, I knew quite a bit about obstructive sleep apnea, and what I feared most was a stroke or heart attack. In constant pain and debilitated most of the day, all I could think about was ending my life.
But I got very lucky. A friend of mine who had a headgear-based orthodontic treatment course similar to mine and who had battled similar issues discovered a dentist in Australia who had invented a bite-plate that freed the lower jaw from being trapped behind the upper jaw. As a last resort and a desperate last hope, I booked a flight to Australia. I arrived on April 4th 2015, and I wore my appliance to sleep for the first time on April 6th. For the first time in my life since I was 11 years old, I woke up naturally. It was a religious and transformative experience for me and I phoned home and wrote to my closest friends. I celebrated that night and took the dentist and his family out for dinner. What I'll never forget is the look on the dentist's face when I gave him the good news. It was 7am, and I was at house eating breakfast. He was standing and eating and I was sitting at the dinner table. When I told him how I had slept, and that I hadn't slept like this since I was a kid, he looked at me blankly, took a bite of his toast and the look on his face said "and the sky is blue...why are you surprised?", as though he's seen this day in and day out. After he put his toast down, he picked up his coffee and right before his next sip, he mumbled "good, keep it up." It was truly no big deal for him, just another Tuesday. I now call him the miracle worker. By April 9th, I had woken up refreshed three days in a row and the scalpel-sporting worm crawling through my head and eyes was no longer there. I got back to Vancouver on April 14th, and the past two mornings have been nearly painless with 8 hours of straight sleep each night. I regained hope in my life and in my health. I also regained a sense of motivation at work, because waking up earlier and not being fatigued means that I have more hours in the day to be productive. For the first time in my adult life, I now understand how a person can have time for a workout, to eat breakfast and to read the paper in the morning. By the way, the dentist's name is Dr. Joseph Da Cruz. I want to give him credit and thank him not just for putting me up in his home the entire week, but for saving my life.
Dr. Da Cruz explained to me the dangers of stunting the growth of any part of the skull. He explained that with headgear, the maxilla cannot come forward to it's genetically-intended position and that with retainers, a child's jaws cannot widen while they sleep. He explained that during growth, the nerves, arteries, veins and soft tissues of the skull need room because they are expanding. A headgear will push the maxilla back, using the spine as a fixation point. He pointed that first of all, the spine is not fixed, it moves. Therefore, headgear can in fact displace the vertebra that it pushes against in a growing child. Secondly, he pointed out that not only is the spine impacted, but when the maxilla is held back, other bones in the skull are also held back, and this includes every bone between the spine and the maxilla, which all hold the brain. These bones include the sphenoid and the occiput. He looked at my CT scan and showed me how certain points in my skull were too far back from their correct anatomical positions, and explained how backwards forces in there areas exert compression on nerves, arteries and veins. The problem with this, he said, is that we don't know the degree to which this affects blood flow and neural signaling, but he said that these are essential for good sleep, which is essential for growth and healing, which is why he doesn't dare restrict any growth in a child. One of the problems, he said, is that when growth is stunted and the jaws are smaller, the airway becomes smaller. Because the tongue grows to it's normal size during the headgear phase of orthodontic treatment, it then appears large, and is too large for the airway when the mouth is closed during sleep. To compensate, the person starts to breathe through their mouth, and the muscles that facilitate breathing have to work unnaturally in order to keep the mouth open. This unnatural muscular pattern further retrudes the jaws because when the mouth opens, the lower jaw comes down and back. He explained to me that we needed to release the muscular stain pattern I had, which would allow the lower jaw to be released forward. This, he said, would decompress my TMJ, and may reduce pressure on nerves, veins and arteries. He said that the light maxillary expansion created by his appliance would expand my capacity to breathe through my nose, because the base of the maxilla forms the base of the nasal airway, and this expansion, also in the forward direction, would also help bring my lower jaw forward, untrapping it from my backwardly positioned maxilla, helping me to breathe better at night.
Two years ago in April of 2013, when I was told that my airway was one quarter the size it should have been, and that this was so because my maxilla and mandible were not far forward enough, I immediately recalled the first appointment I had with the orthodontist, during which he told me that my upper jaw was overgrown, and that we would have to restrict its growth with headgear. I recalled his statement that there were no alternatives other than extractions, and no side-effects other than an overgrowing lower jaw which could easily be corrected and happened rarely. After recalling that, I began searching scholarly journals for the negative effects of headgear and growth restriction and I discovered that since the mid 1900s, cervical headgear was under controversy due its ability to cause the maxilla and mandible to grow downward and backwards, unpredictably. I found journals that were decades old, in which orthodontists stated that cervical headgear did more harm than good, and referred to the side effects as "disastrous." I then learned that the orthodontic profession was divided into camps, those who favored headgear and those who did not, and that there were alternatives to headgear at the time that did not rely on growth restriction as a means of alleviating crowded teeth and undergrown mandibles. I also discovered orthodontic journals dating back to the early 1900’s, in which the practitioner and writer states that a poorly or backwardly grown maxilla can cause an upper airway obstruction, and that this could both change the shape of a person’s face for the worse by forcing them to be an oral breather, and wreak havoc on their health through poor breathing during sleep and constant fatigue. More alarming, I found a 1986 paper published out of the University of British Columbia by an orthodontist named Dr. Allan Lowe, who is now the head of the UBC Orthodontic Division. In his paper, he states that a tell-tale sign of sleep apnea is a backwardly positioned maxilla and mandible, and a steep occlusal plane, which we know are clinically observed and documented side effects of cervical headgear.
Add insult to injury, I also discovered a set of papers that analyzed the craniofacial growth of a child, and the conclusions are that the upper jaw comes out first, followed by the lower jaw that grows roughly one and a half times faster than the upper jaw during adolescence. In other words, children can be naturally buck-toothed and that this tends to correct itself over time.
After I read Dr. Lowe’s paper, I was in shock. I thought to myself:
“My orthodontist must to have known about Dr. Lowe’s work. They worked together. He also must have known about the controversy of cervical headgear and the observed side effects of a backwardly grown maxilla and mandible and steepened occlusal plane. He had to have known about some of the papers that connected disordered breathing to a backwardly positioned and constricted maxilla. Therefore, he must have known at the time that cervical headgear, by pushing my maxilla backwards into the space of my airway, could have caused me to have a narrowed airway, which in turn, could have caused sleep apnea. Did he conceal all of that from me, when I was 11 years old and asked him about side effects? Or, was he simply not paying attention to what was being published?”
In either case, I felt that had he revealed to me what he knew about observed side effects, or had he been up to date on what his peers knew about headgear, my lifelong battle with fatigue could have been prevented. I also thought about his use of fixed-width upper and lower Hawley retainers that I wore during growth spurt years. I have since learned that they are designed to restrict the lateral growth of the jaws so that the teeth remain where the orthodontist put them, and was never told of this other deleterious impact – the impact of limiting the effects of normal lateral growth – which also impacted my airway, by forcing my jaws, and hence my oropharynx within them, to be more narrow than they were genetically intended to be. Had I not worn growth restricting orthodontic appliances, my face and jaws would have been allowed to grow without restriction, and my airway would have been larger.
I then called a few dentists I knew, and asked about my orthodontist's reputation. I was told that he was “old school, and definitely a ‘headgear’ man”. I also discovered that the orthodontic industry is made up of camps - the “headgear" and "no-headgear" camps, and the "expansionist" and “extractionist" camps, among possible others. I then started contacting orthodontists all over the world, and I discovered that these camps have literally been at war with each other, and I came to the conclusion that those in the "headgear" camp had to have known about the side effects pointed out by the opposing camps, and can only be in deliberate denial towards their patients in order to maintain their methods, otherwise, if they were transparent about the known side effects, no patient would consent to the corresponding treatment. In regards to those in the "no headgear” camp, the reason they stopped using headgear is exactly because of its observed side effects – a backwardly positioned maxilla and mandible.
Had I known about all of these deleterious effects surrounding the use of cervical headgear and fixed-width retainers, I would have certainly declined treatment and would have rather lived with crooked teeth and an overbite than a compromised airway, and I think the option to choose should have been mine, not an orthodontist’s to induce me to accept through false statement s and material omissions.
I can only conclude that seeing that orthodontist that day when I was 11 years old was simply my luck of the draw. It was hard to question him in my own mind as a kid, especially given the stature he had reached in his field, that he came from a top school, and was highly respected and influential at least locally. I expected that I was getting the best treatment from him, so I gladly wore my headgear, every night, without fail. Little did I know that it was stunting the growth of my airway. Little did I know that in his profession, his peers were loud and clear about the damage that cervical headgear could have on a person. And, little did I know, that there was a war going on in his profession in which children bore the casualties.
Every day, I wonder how many kids have a major portion of their lives mapped out in one meeting with an orthodontist who either isn’t aware of the damage his work can do, or chooses to ignore the calls of his peers, and then hides these calls from patients. All in the name of what?
I also question why our society deems growth restriction of the jaws to be an acceptable practice. If a doctor told you that your child’s feet were too big and needed to be restricted with metal foot-gear, how would react What if a doctor told you that your child’s ribcage was too wide, and needed to be restricted with a metal corset? I’m almost sure you would understand that this process would destroy a child, because the heart, lungs and other organs within the rib cage are growing. Is restricting the maxilla by banding it against the back of the neck any different than restricting any other body part? Just as the ribcage holds vital growing organs, so does the space between the neck and the maxilla. Within that are arteries, veins and nerves connected to the brain, the pituitary gland, the tongue, and most importantly, the airway. I cannot imagine that restricting the space of a growing airway, or any growing part of a child, could ever be healthy.
I purport that my orthodontist’s use of headgear was not rooted in common sense and was not generally accepted by his peers, given what is published. I also note that my orthodontist did not refer me to a medical specialist when he diagnosed me with an overgrown upper jaw, and that as an orthodontist, it was not in his place to make such a diagnosis, but rather, he should have made a referral to a specialist doctor, as recommended in some of the orthodontic journals I have read. I also purport that he did not respect what was medically known at the time regarding the growth patterns of the lower jaw in children, which is that it generally catches up to the maxilla with timing that cannot be predicted, and that had he respected this, he would have recommended that we let my lower jaw come out on its own, without interfering in my growth. Additionally, the prescription of cervical headgear was not done in full disclosure to me of the side effects that were known at the time, and therefore, my orthodontist never obtained my consent to treat me with cervical headgear.
Finally, given that the effects of cervical headgear on craniofacial growth are still not yet fully understood by the orthodontic industry, nor were they understood in 1990 when I wore headgear, and given the fact that the use of cervical headgear is still in debate today, and the fact that its safety has never been established, and that it has been proven time and again to be predictably unsafe, I would say without a doubt that it is still an experimental treatment. And I see no basis for us to conduct experiments to better understand its effects, as experiments of growth restriction would be inhumane should never be performed in the first place.
By the known facts of our anatomy, the base of the maxilla forms the nasal airway. Any restriction on the growth of the maxilla restricts the growth of the airway, be it through cervical headgear or other means. I, therefore, hold my orthodontist responsible for restricting the growth of my airway and causing me to have obstructive sleep apnea. I cannot even say that he contributed to it and worsened and existing condition, because fatigue was never an issue for me up until I started to wear headgear. Either he willfully concealed known alternatives and side effects, or if we was unaware, he willfully concealed that he had not checked for alternatives and side effects. Whether he knew what he was doing or not, he had everything in his power to know this in 1990. His actions towards me have caused me grave harm and loss which could have been prevented and cannot be fully repaired.
I have since started Right to Grow. It is an organization with a mission to educate parents about the dangers of growth restriction on the airway, and to ban the use of growth restriction on children.
The 1959 Declaration of the Rights of the Child, states in Principle 2:
“The child shall enjoy special protection, and shall be given opportunities and facilities, by law and by other means, to enable him to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity. In the enactment of laws for this purpose, the best interests of the child shall be the paramount consideration.”
I ask you, does restricting the normal growth of a child’s upper jaw allow him to develop physically in a normal manner?
On November 20th, 1989 the International Convention on the Rights of the Child was adopted as a binding treaty by 176 nations at the UN General Assembly. It was based on the 1959 declaration. This new document states in Article 6.2:
“States Parties shall ensure to the maximum extent possible the survival and development of the child.”
In Article 24.3, it states:
“States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children.”
How many more children need to suffer as a result of having their natural growth impeded, before we can abolish from our society what needs to be abolished?
If you want to take action, print out the research on this website along with Article 24.3, and feel free to use my story. Present it to your local government representative. Get in touch with your local parent-teacher association. Make live presentations to those groups in school gyms. Go to community organizations, ask them if you can present to an audience of parents. You don't have to be a doctor or an orthodontist to have a say here. The information contained in the "Research" section speaks for itself and you can use it. The scientific papers it refers to were written by doctors and orthodontists. Parents, more than anybody, need to know where and when their kids are at risk.
If you know a healthcare professional who stands by what has been said here, get them to write a letter of support. That will only add more credibility to an effort to change our laws.
If you have a similar story, write in. If you know of any other people who have similar stories, and I’m sure there are many, get them to write in. The more stories we have, the more power we have to move forward.
I can be contacted at [email protected]
To give you an idea of how dangerous orthodontic growth stunting is, and what vertical and backward growth of the face looks like here is my face the summer before I started wearing headgear.
The next picture is me about two years ago.
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In what country was your orthodontics originally done?
Treatment is easier at a younger age not because there is any growth left, but because the bone is more vascular and easier to remodel as teeth are moved in the bone. Movement really starts to slow down in the 40s, although I did one case in a woman of 76 successfully.
My guess is they are going to use the implants for anchorage, as they never move. I started a case like this as well, only being stopped for the moment because of the COVID virus. The tricky thing is estimating when you want the implants to go, knowing that the rest of the teeth will be moved. Implants, either temporary or permanent, are our modern alternative to headgear.
Your guys sound like they know what they are doing. If they want to use those expensive Damon brackets, let them. Good luck in your retreatment!
Unfortunately I have no before and after photos from my previous treatment’s as none were taken…
I was thinking with yourself, I am very fascinated with the subject leading to me constantly having questions, not sure whether this much help for me, as the issue is very troubling.
I am very privileged to be able to have the opportunity to be seen by the people I am with at present. I believe the Damon system is a lighter bracket? Which I would imagine would be more beneficial for someone of my age.
I started treatment at 26, I am now 28. The implants (replacing extracted teeth) I need are for my bottom jaw, Iv been told this easier to accomplish than if the implants were in the top jaw provided there is enough space to created in the top jaw via the brackets and tongue posture and then equal of space is created in the bottom jaw with the brackets.
The team that are seeing me are confident that significant improvement can be made. I have heard many conflicting opinions about what can be achieved the variable that appears the most is age, I assuming this is due to there being no more growth? In any case I am gradually feeling and seeing improvement.
Online meetings with who? Don’t understand. If you merely want to review your condition NOW, send me a current ceph and profile photo. But I will miss a lot of detail I get with an in-person exam.
You are talking about Damon brackets and Temporary Anchorage Devices? Or regular implants for replacing teeth? Either provides good anchorage.
Damon brackets are not magic and overpriced. They can work like many brackets can. I took a Damon course and they are overhyped.
But is sounds like whoever you are seeing is on the right track. What was that orthodontist’s conclusion about your current condition?
I don’t wish to waste your time, I’m afraid I don’t have that level detail to show you. I could potentially get hold of x rays that I had when I was much younger.
At present I am aiming to correct my problem via the Damon system and hopefully implants. Are online meetings available?
‘One of the traits of humans is they always want to assign a cause when something bad happens to them. The want to blame someone or something. It makes them feel vindicated.’
I agree with this wholeheartedly, I am guilty of it, though I aim not to be.
Would I able to send them to you via email?
You are right that there is always nature and nurture in skull and facial morphology.
That being said, the quality of dentistry is very poor in England and it could well be that you were mistreated.
I have suffered the same fate as Omar with just exactions and braces. My whole face has changed for the worst and my health is declining rapidly, would it be alright if i showed you some before and afters?
In the 1970s and early 1980s we had mainly headgear and class II elastics to correct class II occlusions. A few people used Frankels but they were expensive and damaged easily. And the compliance in wearing was not much better than headgear.
Now we have temporary orthodontic implants, Herbst appliances, and other modalities. Headgear would still be useful anchorage for some cases, but try to get kids to wear them even part time these days.
To my knowledge, there is still not much to control excess vertical growth except high-pull headgear. Overcoming aberrant inherited growth tendencies is a difficult endeavor.
It is tempting to read a website and start blaming all one’s problems on someone or something. Fact of the matter is bad things happen to people for no particular reason. For example, my left kidney produced a lot of stones and I lost it. There is no way Omar could have turned out so retrognathic without a generic predisposition for it. And many times with such retrognathism comes sleep apnea.
“Crap” is a vulgar word now?
For what it’s worth, here is likely explanation of what REALLY happened to Omar:
1. He inherited the tendency toward a short mandible. This is fairly common in Caucasians. In his case, the trait was expressed only as he headed into puberty.
2. His was probably a marginal crowding case, the type we would treat by expansion or stripping these days. In those days some orthodontists tried RETRACTION headgear to generate more space.
3. In the process, the torque to anteriors was not controlled, and the upper incisors were retroclined.
4. These retroclined upper incisors MAY have resulted in a restrictive effect to the mandible, thus minimizing Omar’s small genetic potential for growth. Proper incisor torque and possibly a Herbst would have POTENTIATED mandibular growth potential.
5. A very common finding in sleep apnea patients is retrognathia. The tongue is carried to far posteriorly, and blocks the soft palate.
HOWEVER, it is sheer conjecture if Omar’s mandible would have grown more anteriorly without any orthodontic intervention. In treatment, sometimes we get lucky in growth, and sometimes we do not. A late growth spurt (even at age 18) in people with long mandibles often completely goofs up perfect orthodontic treatment.
ALSO, I see many patients (one yesterday) who have severe sleep apnea because of the drape of their soft palate, and ARE NOT retrognathic at all. To blame all sleep apnea on extraction orthodontics and/or headgear is intellectually infantile.
If someone has had something “negative” happen to him, they have the “right” to believe and propagate any NONSENSE they find on the internet? That is what you contend???
It’s America, you see. Anyone having any problem has the RIGHT to blame someone for their problem. When they should be blaming their own genetic makeup.
Doubtless some orthodontic misdiagnoses occurred in the past. Possibly on this one. But I can tell you this with certainty: this man’s atrophic mandible had NOTHING to do with headgear he may have worn during orthodontics.
I have practiced dentistry for 40 years and orthodontics for 30. I tutored under a couple really good orthodontists and attended three Arab orthodontic conferences as well as many others. But no, I did not do an ortho residency. Did you? You think I haven’t done any case studies? Only on every case I treat. I have done pre-and post-treatment cephs to analyze what happened during orthodontics. Have you?
NOBODY can know the underlying skeletal measurements without cephs. The naso-labial angle looks similar in both photos, meaning the maxilla position did not move much if any.
Why do you people obsess over headgear when no one has used them for a long time, except reverse pull face masks on very young patients?
The subject of dental insurance has nothing to do with the validity of treatment modalities. Most insurance employees don’t know crap about treatment, and you are a prime example!