“Moderate to severe obstructive sleep apnea is independently associated with an increased risk of stroke, cancer and death”
American Academy of Sleep Medicine, 2014
The following research anthology connects the dots between orthodontic growth restriction via headgear and obstructive sleep apnea. The research is organized into five parts.
It attempts to prove that the industry has been aware for decades that growth restriction via headgear can have disastrous effects on respiration and quality of life in general, and that in the name of science and care for the wellbeing of patients, these practices need to be stopped.
In Part I, you will find numerous studies going as far back as 1953 illustrating that headgear has been observed in many cases to cause a backwardly positioned maxilla and mandible.
In Part II, you will find another set of studies that show how a backwardly positioned maxilla and mandible contribute to serious and disastrous respiratory problems; these papers date back to 1915.
In Part III, you will find a set of papers that make a direct link between orthodontic growth restriction and obstructive sleep apnea. Take special note of a paper published in the Spring 2007 Issue of the Journal of the American Orthodontic Society where one orthodontist is calling to his peers to put stop on growth binding procedures, because they are not fully understood, and can cause disastrous and lifelong effects on health.
Part IV illustrates the dangers of using fixed retainers, which are designed to restrict natural widening of the jaws.
Part V, finally, is an excerpt of a letter from an orthodontist to his peers, whereby he explains that the industry is divided into camps – “headgear” and “no headgear”, or “extractions” and “no extractions”. He explains that “camps” perform orthodontic work in a manner that is based on allegiance to factions, and not rooted in science and patient care. He calls this a subversion of patient trust. He calls for orthodontists to be honest with the public, and get out of the blindness of camps.
If there is a “no headgear” camp, then by default there are orthodontists who have been taking heed of the message in the research presented here. And, if there is a “headgear” camp, then, by default, there are orthodontists who either need to be made aware of the dangers of growth restriction, or who are in willful denial of the known facts.
Part I: Headgear Causes Reverse Growth Patterns
1937 - From the the age 2 to 12 years old, the mandible grows at a faster pace the maxilla, both in the vertical and in the AP (front to back) direction. (Young, M.: Normal Facial Growth in Children, Journal of Anatomy, Vol 71, Pt. 4, July 1937, p. 458-470)
1953 - Generally, the overbite decreases somewhat with age. In extreme overjet cases, the mandible tends to advance to a greater degree with age, as compared to non-extreme overjet cases. (Bjork A.: Variability and age changes in overjet and overbite, American Journal of Orthodontics, Vol 39, Iss 10, October 1953, p. 800).
Note from Right to Grow: These are unique papers in that they raise the question as to which degree orthodontic intervention is necessary in overbite and overjet cases. Since the mandible grows at a faster rate than the maxilla, can you really look at an 11 year old kid who is bucked toothed, and say that this kid needs treatment? The mandible might not be done growing, and it may be growing very quickly, so perhaps there is a good reason to wait until growth is finished before concluding that there is a problem. Also, given that the mandible will advance forwards to a greater degree in non-treated patients than in treated patients, as we know from Waston's work in 1972 and Baumrind's work in the early 1980's, perhaps no treatment is better than conventional orthodontic treatment.
1957 – With cervical headgear, the palatal plane was tipped downward; the growth of the basic maxilla has been altered; in some instances rotation of the mandible appeared far greater than would be expected in normal behaviour; cervical headgear steepened the mandibular plane – this is undesirable. (Klein, P. L.: An Evaluation of Cervical Traction on the Maxilla and the Upper First Permanent Molar, The Angle Orthodontist, Vol. 27, No. 1, January 1957, p.61-68).
1960 – Without treatment, the facial angle improved to a greater degree than with treatment; the mandible came forward at a slower pace with treatment; improvements in the facial angle were slightly inhibited by cervical headgear; cervical anchorage tended to steepen the mandibular plane angle or lengthen the face much faster than usually observed with normal growth; the maxilla was observed to grown in a downward and backward direction; the whole middle face was being altered with treatment; the occlusal plane was held downward with cervical headgear. (Ricketts R. M.: The Influence Of Orthodontic Treatment On Facial Growth And Development, The Angle Orthodontist, Vol. 30, No. 3, July 1960, p.103-133)
1963 - Headgear was observed to redirect normal growth in the downwards and backwards direction; the anterior nasal spine was affected in the same way; the whole maxilla is being positioned downward and backward as a result of headgear; the mandibular plane is steepened with less forward movement of the chin; clockwise rotation is observed; the relationship between the sphenoid bone and other bones in the craniofacial complex is altered and these growth patterns are not seen in untreated children. (Wislander L., Tandlakare L.: The effect of orthodontic treatment on the concurrent development of the craniofacial complex, American Journal of Orthodontics, Vol 49, No 1, January 1963, p.22-26)
1967 - Downward tipping of the palatial plane caused as a result of cervical traction has been reported, which could not be attributed to normal growth; rotation of the sphenoid bone has been observed as a result of cervical traction; less forward movement of the chin has been reported in treated versus untreated patients along with a downward and backward rotation of the mandible; cervical traction can steepen the mandibular plane and this is an undesirable change. (Poulton D. R.: The influence of extraoral traction, American Journal of Orthodontics, Vol 53, No 1, January 1967 p.9-11)
1967 - Cervical headgear must be used with caution, as it can be a potent evil force. (Funk A. C.: Mandibular response to headgear therapy and its clinical significance, American Journal of Orthodontics, Vol 53, No 3, March 1967, p.185)
1967 - Facial growth pattern is changed by orthodontics; in untreated cases, the mandible comes one to one and a half times faster than the maxilla with significantly more forward chin movement – this is significantly more than in headgear treated cases; isolated cases show the maxilla moving backwards with headgear treatment; the mandibular plane angle is steeper for headgear treated cases and this is what brings the chin back; with headgear, the face grows significantly more in the vertical direction; the mandible comes forward significantly less; the vertical response is disastrous; the face can become dished-in; cervical headgear should not be used for high SNB angle (retrognathic) faces; PNS to lower mandible is seen to reduce with infraerupted molars. [Contrary to overerrupted molars seen in studies involving other vertically grown faces] (Creekmore T. D.: Inhibition or Stimulation of the Vertical Growth of the Facial Complex, Its Significance to Treatment, The Angle Orthodontist, Vol. 37, No. 4., October 1967, p.285-297
1970 - Extensive use of cervical traction has caused controversy regarding its effects on the craniofacial skeleton of a growing child; it has been shown to result in downward tipping of the palate, lack of forward chin movement, clockwise rotation and inhibited forward growth; clinical evidence points to the fact that cervical traction can be harmful to the dentofacial skeleton of a growing child. (Ringenberg Q. M., Butts W. C.: A controlled cephalometric evalauation of single-arch cervical traction therapy, American Journal of Orthodontics, Vol 57, No 2, February 1970, p.179, 180 & 184)
1970 - Cervical facebow treatment, which is similar to cervical headgear, has been shown to cause tipping of the palatial plane, backward growth of the maxilla, backward and downward rotation of the lower face in general; these are undesirable changes; the evidence of backward and downward growth of the lower face should raise concerns about the use of such retractive forces; there is little cranial growth during orthodontic treatment; forward growth is opposed; this treatment should not be used, and if so, should only be confined to short periods; these abnormal growth reactions - backward growth and tipping - are serious and disastrous; in one study, 54% of facebow-treated had downward and backward facial growth and 46% had forward growth - 88% of untreated controls showed forward growth. (Merrifield L. L., Cross J. J.: Directional forces, American Journal of Orthodontics, Vol 57, No 5, May 1970, p. 435-463)
1972 - Cervical traction rotates the mandible downward and backward and causes mandibular growth to no longer be expressed in the horizontal direction when cervical traction is not paired with extractions to relieve the wedging acting between the maxilla and the mandible. (Watson W. G.: A computerized appraisal of the high-pull face bow, American Journal of Orthodontics, Vol 62, No 7, December 1972, p. 567, 568, 574 & 578)
1974 - Cervical traction was observed to have the effect a of changing normal growth patterns with downward and backward movement of the maxilla, a steepening of the mandibular plane, a more backward positioned chin and clockwise rotation of the sphenoid bone; many other investigations have seen this. (Wieslander L.: The effect of force on craniofacial development, American Journal of Orthodontics, Vol 65, No 5, May 1947, p.531-537)
1974 - Cervical traction causes the maxilla to grow in a posterior manner, a steeper mandibular plane angle, rotation of the sphenoid bone and posterior displacement of the chin; these growth changes remain stable. (Wieslander L., Buck D. L.: Physiologic recovery after cervical traction therapy, American Journal of Orthodontics, Vol 66, No 3, September 1974, p. 299 & p.301)
1975 - Cervical headgear causes the palate to tip downward and backward and causes the chin to move back in some cases which results in a dished-in face; this is an abnormal and undesirable growth pattern and even after treatment this patters continues; cervical traction does more harm than good. (Brandt S.: Dr. Terrell L. Root on Headgear, Interview, Journal of Clinical Orthodontics, Vol IX, No 1, January 1975, p. 23-25)
1977 - Orthodontic treatment did not improve facial growth; faces grow better before treatment; during treatment there is little mandibular forward growth with a retardation of the development of the middle and lower face; several patients exhibited a clockwise deviation in normal growth whereby growth direction was changed from horizontal to vertical or slightly backwards; these changes are difficult to predict, not beneficial in nature and orthodontics should be confined to correcting tooth movement and not facial growth. (Cross J. J.: Facial growth: Before, during and following orthodontic treatment, American Journal of Orthodontics, Vol 71, No 1, January 1977, p.69-77)
1978 - The extrusion of the upper first molar, as caused by cervical headgear, is responsible for a number of pernicious effects upon face form; retractive appliances hinder a closing of the mandibular plane angle which is happens in untreated children as part of their development process; the combi device and cervical headgear create the most variability in the deviation from normal growth in mandibular plane angle. (Baumrind S., Molthen R., West E. E., Miller D. M.: Mandibular plane changes during maxillary retraction, American Journal of Orthodontics, Vol 74, No 1, July 1978, p.33, 38, 39)
1978 - Retraction of the upper first molars, or retraction of the maxilla to correct a Class II malocclusion tends to cause the mandibular plane angle to open, and this is associated with relative failure of the body of the mandible to grow. (Baumrind S., Molthen R., West E. E., Miller D. M.: Mandibular plane changes during maxillary retraction, Part 2, American Journal of Orthodontics, Vol 74, No 6, December 1978, p.617 & p.620)
1978 - Cervical headgear tips the maxilla and mandible downward and backward, i.e. the functional occlusal plane is tipped downwards, relative to normal growth, whereas high-pull headgear does not seem to have this effect. The forces applied by headgear have the potential to cause periodontal tissue loss. (Brown P.: A cephalometric evaluation of high-pull molar headgear and face-bow neck strap therapy, American Journal of Orthodontics, December 1978, p.630-631)
1981 - Clinicians tend to treat patients based on their preferred appliances, rather than the dento-skeletal characteristics of the individual patients; the opposite should be the case. In most Class II cases, the maxilla is not protrusive but often it is treated as though it is. Rather, it is normal or retrusive and this has been observed in multiple past studies. The craniofacial abnormalities seen in Class II cases are normally a retrusive mandible which has been shown to be corrected through proper muscle function and jaw posture, vertical facial height and steep mandibular planes, which can be exacerbated by construction of the nasal airway [which happens through maxillary restriction]. Therefore, in treating Class II cases, an approach that alters the mandibular growth could be more appropriate than approaches that restrict maxillary growth [headgear, for example]. (McNamara, James A.: Components of Class II Malocclusion in Children 8-10 Years of Age, The Angle Orthodontist, Vol 51, No 3, July 1981, p.177-202)
1981 - Cervical headgear increases vertical growth of the face significantly, compared to non-treatment. (Baumrind S., Korn E. L.: Patterns of change in mandibular and facial shape associated with the use of forces to retract the maxilla, American Journal of Orthodontics, July 1981, p.45)
1981 - Rate of growth of mandibular body length is greatest for untreated patients, and significantly reduced for patients with cervical headgear in such a way that the mandible does not appear to be freed to grow forward; we should reassess the effect of growth changes induced by cervical headgear on posture and respiration. (Baumrind S., Korn E. L., Molthen R., West E. E.: Changes in facial dimensions associated with the use of forces to retract the maxilla, American Journal of Orthodontics, July 1981, p.27)
1983 - Cervical headgear causes a downward and backward tipping of the palatial plane that is not observed in untreated patients. (Baumrind S., Korn E. L., Isaacson R. J., West E. E., Molthen R.: Quantitative analysis of the orthodontic and orthopedic effects of maxillary traction, American Journal of Orthodontics, Vol 84, No 5, November 1983, p. 392, 397, 398)
1984 - Cervical traction of the upper molars would tend to cause a backward rotation, which is an increase in the mandibular plane angle. The ability of clinicians to predict whether a patient is predisposed to backward rotation prior to treatment is poor. (Baumrind S., Korn E. L., West E. E.: Prediction of mandibular rotation: An empirical test of clinician performance, American Journal of Orthodontics, November 1984, p.373, p.371)
1988 - Cervical headgear inhibits forward growth of the maxilla and causes downward tipping of the anterior part of the palate. (Canglatosi T. J., Meistrell M. E., Leaung M. A., Ko J. Y.: A cephalometric appraisal of edgwise Class II nonextraction treatment with extraoral force, American Journal of Dentofacial Orthopedica, Vol 93, No 4, April 1988, p. 315)
2007 – Cervical headgear patients showed a significantly retruded and restricted maxilla and a reduced mandibular protrusion angle as compared to those undergoing mandibular protraction therapy, who experienced greater increases in mandibular length. Siqueira D. F., de Almeira R. R., Janson G., Brandao A. G., Filho C. M. C.: Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions, American Journal of Orthodontics and Dentofacial Orthopedics, Vo. 131, No. 4, April 2007, p.447.e21-447.e30)
2012 - Headgear has been proven to have not only a growth stunting but a retrusive effect on the maxilla; the effects of headgear and its use have long been under controversy; headgear flattens the cranial base. (Alio-Sanz J., Iglesias-Conde C., Lorenzo-Pernia J., Iglesias-Linares A., Mendoza-Mendoza A., Solano-Reina E.: Effects on the maxilla and cranial base caused by cervical headgear: A longitudinal study, Med Oral Patol Oral Cir Bucal., Vol 17, No 5, September 2012, e845-51)
Part II: Reverse Growth Patterns Lead to Respiratory Problems
1915 – The subject of palatial and maxillary deformity – in connection with mouth-breathing and nasal obstructions – has been discussed ad nauseum by rhinologists and orthodontists; the orthodontist has the capacity to remould the narrow, deformed maxilla to a normal shape by widening it to restore the power of breathing through the nose; a normal balance of the forces of growth and muscles induces normally-shaped bone and when any of these forces are out of balance, deformity ensues; the growth and width of the jaws are concurrent with expansion of the nasal chambers; even a trifling encroachment upon the free space in the nose, by septal deviation by the reduction in its total transverse diameter, seriously reduces its capacity and hinders nasal breathing; the narrow palate is typically associated with a deviated septum; an infant’s bodily strength was observed to be dangerously weakened by loss of sleep resulting from nasal obstruction; the narrow palate and subsequent nasal obstruction reduces health so much so that it shortens life. (M’Kenzie D.: Some Points of Common Interest to the Rhinologist and the Orthodontist, International Journal of Orthodontia, Vol. 1, Iss. 1, January 1915, p.9-17)
1915 – Abnormal development of the dental arches results in abnormally developed nasal passages; nasal respiration will be difficult when the jaws are underdeveloped; Dr. Angle – the celebrated orthodontist – stated as priorities to orthodontics and in order of importance that proper occlusion must be established first, then harmony of the jaws, and lastly, improvement of the facial lines; to Dr. Angle’s list I would make the first priority as the establishment of proper breathing through the nose; breathing through the nose, rather than the mouth, is critical to our health; widening the maxilla lowers the vault of the palate, which deepens the nasal cavity, and in many cases this corrects deviated septums. (Myers D. W.: The Relationship Between Rhinology and Orthodontia, International Journal of Orthodontia, Vol. 1, Iss. 2, February 1915, p.87-99)
1916 – Mouth breathers tend to be backward physically and mentally; development of the maxillary bones results in a consequent increase in size of the nasal cavity; many mouth-breathing cases have been solved by stimulating growth of the maxilla, by applying gentle forces to widen the dental arches – such children after expansion treatment from an orthodontist exhibit improved general health; patients who are not receiving the full benefit of modern science unless they have an opinion from both the rhinologist and the orthodontist; the practitioner who does not bit the patient consult with the other specialist is occupying a position that is indefensible. (Ketcham A. H.: Treatment by the Orthodontist Supplementing That by the Rhinologist, International Journal of Orthondontia, Vol. 2, Iss. 1, January 1916, p.15-28)
1921 – The orthodontist should be working in conjunction with the rhinologist and pediatrician; mouth breathing cannot be cured unless there is normal development of the maxilla; mouth breathing is associated with a deep hard palate and a mandible that is drawn downward and backward. (Bilderbak J. B.: The Relation of the Physician to the Orthodontist, International Journal of Orthodontia and Oral Surgery, Vol. 7, Iss. 8, August 1921, p. 412–418)
1924 - The maxilla forms the greater part of the nose and particularly the floor of the nose which is most concerned with respiration; cramping of the maxilla produces a narrow obstructed nose and it is here that the orthodontist must help the rhinologist by developing the maxilla; a poorly developed maxilla is associated with nasal respiratory problems and mouth breathing; nasal respiratory problems show up at night while the patient is sleeping; mouth breathers typically have speech issues, are succeptible to hearing loss, congestion, frequent colds and inevitiable loss of time at work due to illness; mouth breathers are typically slouched with their faces thrusted forward, those typical features are not the perfect picture of health; treatment of mouth breathing should be done by expanding the maxilla with a dental appliance. (Davis, E. D. D.: The Causes and Effects of Mouth Breathing, International Journal of Orthodontia, Oral Surgery and Radiography, Vol 10, Iss 8, August 1924, p.483-493)
1931 – There is a relationship between obstructed nasal breathing and narrow, high-arched, poorly developed maxilla; every rhinologist and orthodontist knows this; a high-arched narrow and under-developed maxilla is associated with a deviated septum, which results in obstructed nasal breathing; the more the maxilla lags in growth, the greater the predisposition nasal obstruction and mouth-breathing. (Morrison W. W.: The Interrelationship Between Nasal Obstruction and Oral Deformities – The Action of Obstructed Nasal Breathing Upon the Mouth and the Facial Structures; An Historical Review, International Journal of Orthodontia, Oral Surgery and Radiography, Vol. 17, Iss. 5, May 1931 p.453-458)
1976 - Obstruction of the nasopharynx predisposes a shild to chronic mouth breathing, known as respiratory obstruction syndrome; there has been observed a relationship between nasopharyngeal depth and craniofacial base - the more obtuse the base, the greater the depth; the nasal cavity widens throughout adolescence; growth of soft tissues and the nasal airway are in delicate balance if the airway is to be maintained; children with nasal obstructions tend to have vertically grown faces and divergent mandibular planes; the size of the nasopharynx increased 150% from age one to age 17 years nine months for males, and 13 years nine months for females. (Handleman C. S., Osborne G.: Growth of the Nasopharynx and Adenoid Development from One to Eighteen years, The Angle Orthodontist, Vol 46, No 3, July 1976
1976 - A shortened maxilla and flattened facial profile due to a lack of forward growth is associated with nasal airway obstruction; this can affect the development of the face; improvement in nasal airflow can be achieved by rapid expansion of the maxilla laterally, which can influence it to grow forward. (McWilliam J., Linder-Aronson S.: Hypoplasia of the Middle Third of the Face - A Morphological Study, Angle Orthodontist, Vol 46, No 3, July 1976, p.260-267)
1978 - Patients with maxillary retrusion had a high incidence of airway difficultires. (Handler S. D., Beaugard M. E., Whitaker L. A., Potsik W. P.: Airway Management In The Repair of Craniofacial Defects, Cleft Palate Journal, Vol 16, No 1, January 1978, p.17)
1978 - Vertically growth faces, steep mandibular planes and clockwise rotation of the mandible, among other traits, are associated with nasal airway obstructions; rapid expansion of the maxilla can help increase the capacity of the nasal airway; the orthodontist is uniquely in a position to monitor facial growth, should assess the mode of respiration and confer with the otolaryngologist to institute appropriate medical management of any developing problems. (Rubin R. M.: Facial Deformity: A Preventable Disease?, Angle Orthodontist, Vol 49, No 2, April 1979, p.98-103)
1980 - Vertically grown faces and steep mandibular planes, among other traits, have been associated with respiratory obstruction syndrome; rapid maxillary expansion may be effective in improving the nasal airway; obstruction of the nasal airway is followed by the lowering of the mandible to establish an oral airway; the orthodontist should arrange referrals to otolaryngologists and other qualified professionals when excessive vertical growth is seen because there is a risk of nasal airway obstruction in this case. (Rubin R. M.: Mode of respiration and facial growth, American Journal of Orthodontics, Vol 78, No 5, November 1980, p. 504-510)
1981 - A steep mandibular plane, a posteriorly placed maxilla and mandible, and vertically grown faces are associated with mouth breathing, which is an inevitable result of obstruction of the nasal airway; the body's adaptation to mouth breathing results in undesirable facial changes. (McNamara J. A. Jr.: Influence of Respiratory Pattern On Craniofacial Growth: The Angle Orthodontist, Vol 51, No 4, October 1981)
1981 - Retrognathia may be associated with obstructive sleep apnea; maxillo-mandibular advancement surgery and orthodontic treatment is a possible treatment; secondary obstructive sleep apnea can occur in association with many abnormalities of the oro-pharynx; it is necessary to consider the effect of specific maxillo-facial malformations on breathing during sleep due to the possible impact on growth, intellectual development and teh cardiovascular system. (Guilleminault C., Korobkin R., Winkle R.: A Review of 50 Children with Obstructive Sleep Apnea Syndrome, Lung, Vol 159, May 1981 p.275-287)
1981 - Respiratory dysfunction is a constant area of unrest in the field of orthodontics; there is a relationship between obstructed nasal breathing and mouth breathing which is the result of the development and formation the facial structures; the fundamental growth characteristics of the jaw in the developing child cannot be summed up in one word - occlusion; the patient should be informed of the limitations of treatment through informed consent. (Watson W.: Fifty Years of Concern, Editorial, American Journal of Orthodontics, Vol 80, No 5, November 1981, p.561-563)
1983 - The relationship between breathing patterns and craniofacial growth is of great concern to orthodontists; mouth breathing and nasal airway obstructions go hand in hand and are associated with narrow v-shaped maxillary arches, high palatial vaults, steep mandibular planes and vertically grown lower thirds of the face; airway obstruction should be considered in orthodontic treatment; the patient should be informed of the interaction between craniofacial development and breathing, and given the opportunity to see an ENT for an upper airway evaluation. (Shaughnessy T. G.: The Relationship Between Upper Airway Obstruction and Craniofacial Growth, Journal of the Michigan Dental Association, Vol 64, September 1983, p.431-433)
1986 - In a study of 25 adult males with moderate to severe obstructive sleep apnea, several alternations in craniofacial form have been observed, namely a posteriorly positioned maxilla and mandible, a steep occlusal plane, a steep mandibular plane, vertically grown facial height, a posteriorly placed pharyngeal wall, overerrupted maxillary and mandibular teeth, a large gonial angle, and an anterior open bite in association with a long tongue. (Lowe A. A., Santamaria J. D., Fleethan J.A., Price C.: Facial morphology and obstructive sleep apnea, American Journal of Dentofacial Orthopedics, Vol 90, No 6, December 1986, p.484-491)
1991 – Vertically grown faces are associated with nasal airway obstructions, narrow nasal architecture, low-lying tongue postures, steep mandibular planes and clockwise rotations; upper airway obstructions are exacerbated during sleep; overerupted posterior teeth, a common finding on in children undergoing orthodontic management cause the lower jaw to rotate down and back in a clockwise manner; the overall facial pattern can be characterized as “upper airway obstructed faces”; external devices such as reverse cervical collars can reduce these traits; clinicians should be suspicious when chronic nasal stuffiness, oral respiration, vertically grown lower faces and overt orthodontic changes, among others, are observed; delay or absence of intervention may result in unsuccessful orthodontic treatment, necessitating the need for orthognathic surgical intervention; referral at an early age should include otolaryngologic and orthodontic examination, cephalometric radiology, rhinometry and airway patency testing; quality of life deformities and disabilities associated with long-standing nasal obstruction justify serious consideration on the part of pediatricians, dentists and otolaryngologists. (Principato J. J.: Upper airway obstruction and craniofacial morphology, Otolaryngology – Head and Neck Surgery, Vol 104., No. 6, June 1991, p. 881-890)
Part III: Headgear and Obstructive Sleep Apnea – A Direct Connection
1978 – We studied 20 children wearing cervical headgear before their prepubescent growth spurt. All but two showed a partial rebound after their growth spurt. The other two required maxillary advancement surgery because they ended up with obstructive sleep apnea from the maxillary retraction imposed by the cervical headgear. (Melsen, B.: Effects of cervical anchorage during and after treatment: An implant study, American Journal of Orthodontics, May 1978, p.526-540)
1999 – We suggest that headgear therapy may contribute to the occurrence of sleep apnea, when a strong predisposition, such as mandibular retrognathia to the development of upper airway occlusion already exists; the position of the mandible was found to be slightly more posterior in the headgear group than in the control group. The children in the headgear group were found to have significantly more apnea/hypopnea periods during the hours when the appliance was used, and the ODI-index showed increased values in this group. (Pirilä-Parkkinen K., Pirttiniemi P., Nieminen P., Löppönen H., Tolonen U., Uotila R., Huggare J.: Cervical headgear therapy as a factor in obstructive sleep apnea syndrome, Pediatric Dentistry, Vol. 21, No. 1, January-February 1999, p.39-45)
2000 - Cervical headgear has been previously used to restrain maxillary growth; in 1966 it was theorized that the mandible was thrust forward as a reflex in order to counteract a threat to upper-airway patency associated with use of the headgear, however no quantitative data were shown; this experiment has shown that during cervical headgear treatment, the tongue sits in a low-lying position and puts more pressure on the mandibular incisors, and this may be due to the activity of the suprahyoid muscles to maintain adequate airway patency. (Takahashi S., Ono T., Ishiwata Y., Kuroda T.: Effect of Wearing Cervical Headgear on Tongue Pressure, Journal of Orthodontics, Vol. 27, No 2, p.163-167)
2001 – Cervical headgear significantly reduced the upper airway dimensions during sleep by displacing the third cervical vertebrae into the airway; the mandible was observed to thrust forward as a reflexive means of maintaining a threat to the upper airway patency caused by the cervical headgear; the effect that headgear has on the growth of the mandible is still not understood. (Hiyama S., Ono T., Ishiwata Y., Kuroda T.: Changes in mandibular position and upper airway dimension by wearing cervical headgear during sleep, American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 20, No. 2, August 2001, p.161-168)
2007 - OSA is essentially a structural problem whereby the maxilla and mandible are too far back; without realizing that the maxilla is too far back in virtually all malocclusions, treatment is frequently aimed at further retracting the allegedly protruding teeth; bicuspid extraction, headgear, and now temporary anchorage devices (TAD’s) are be used to retract the anterior teeth; the grand majority of all orthodontic care is retractive in nature and the result is a patient with a maxilla and mandible in more retruded positions in most cases following the treatment than at the beginning; children would be better off with no orthodontic care than treatment which in any way reduces the airway; is it not time to completely cease bicuspid extraction, headgear, TAD’s used for retraction, and all retractive mechanics until their effect on decreasing tongue space and possibly producing OSA has been completely resolved with research done by parties with no self interest to protect? (Hang W. M.: Obstructive Sleep Apnea: Dentistry’s Unique Role in Longevity Enhancement, Journal of the American Orthodontic Society, Spring 2007, p.28-32)
2011 – Reductions in pharyngeal airway width potentially triggering or exacerbating obstructive sleep apnea are always possible and should be expected with headgear; more pronounced effects of cervical headgear were obtained in terms of pharyngeal width reductions, not only in the nasopharynx but also at all other levels; pretreatment with a functional appliance such as the Bite Jump Appliance can reduce headgear-related reductions in pharyngeal width. (Godt A., Koos B., Hagen H., Goz G.: Changes in upper airway width associated with Class II treatments (headgear vs activator) and different growth patterns, Angle Orthodontist, Vol. 81, No. 2, 2011, p.440-446)
2012 – Extraction of premolars and retraction of incisors, using headgear or implanted anchors, reduces the pharyngeal airway size, including the velopharyngeal, glossopharyngeal, hypopharyngeal, and hyoid bone position, which was displaced inferiorly – this displacement is an adaptation of the body to prevent the tongue from encroaching into pharyngeal airway; the study was done on adults. (Wang Q., Jia P., Anderson N. K., Wang L., Lin J.: Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion, Angle Orthodontist, Vol. 82, No. 1, 2012, p.115-121)
Part IV - Retention – Is it Dangerous and Even Needed?
1915 – When the jaws are properly developed, and all of the teeth in one jaw articulate with the teeth of the other jaw to furnish the greatest amount of grinding surface, muscular movements of chewing and proper breathing ensure correct form of the dental arches; the interlocking cusps of all grinding teeth in such properly developed dental arches prevent any variation in position of any of the teeth laterally or anteroposteriorly. (Myers D. W.: The Relationship Between Rhinology and Orthodontia, International Journal of Orthodontia, Vol. 1, Iss. 2, February 1915, p.87-99)
1944 – Crowding and rotation is mostly caused a lack of room; in such cases, the creation of the necessary room either by widening or lengthening the of the dental arch, as the case may, will result – and this especially in the maxilla – in spontaneous adjustment of the teeth. Such teeth never relapse. They need neither overrotation nor any kind of retention. Oppenheim, A.: A Possibility for Physiologic Orthodontic Movement, American Journal of Orthodontics and Oral Surgery, Vol 30, No. 7, July 1944. P.354-366)
2012 – “Dr. Amir explained to me how orthodontia as a youngster can stunt the growth of both the upper and lower jaws. The lower jaw actually keeps growing until age 22, and the upper jaw sometime in the late teens. When an adolescent is in braces, they are in a state he calls "negative growth." This means their jaws are not growing at all due to being locked by the braces; bone cannot grow against this resistance. The average child is in braces for 2 years. Then they wear a retainer for 2 years and are again in negative growth (the retainer holds back growth also). When you add these two together, you now have 4 years of negative growth! No wonder people are walking around with recessed lower jaws nowadays. In addition, if a child has teeth pulled BEFORE their jaws reach the mature size (this is never a good idea and I do not recommend it), as an adult they will have a "sunken in" appearance, and again, it will inhibit the full potential growth of their jaws, which has ramifications on the balance and proprioception of the entire body.” (Simonson, D. G.: The Impact of Orthodontia on the Skull, and How NCR and Dental Orthotics Can Help, Dr. Deanna Gail Simonson, 2012, Accessed on November 30, 2014, http://www.drdeannasimonson.com/ncr-for-full-body-orthodontia.html)
Part V: An Industry Divided: Can You Trust Your Orthodontist to be Impartial Over Treatment Method?
1960 – “From this came the revival of wars between the extractionst and the expansionist which was to overshadow other struggles in dental history. (Ricketts R. M.: The Influence Of Orthodontic Treatment On Facial Growth And Development, The Angle Orthodontist, Vol. 30, No. 3, July 1960, p.103-133)
1987 – “Orthodontics has progressed from camps of “extraction” versus “nonextraction,” from “headgear” to “no headgear,” from eyeball diagnosis to cephalometrics, from “heavy forces to “light forces,” from “functional” appliances to, I suppose, “non-functional” appliances. The professional has moved through factions and schisms of “labial appliances,” “lingual appliances,” and “labiolingual appliances.”
The need to be a “Crozat” man, a “Begg” man, an “edgewise” man, or to adopt any other label is inadequate to being a good certified orthodontist. Being an “orthodontist” and doing good “orthodontics,” and the achievement of stable, functional, and esthetic results speak eloquently to our patients and the public...
“I must submit that the fostering of factions and organizations whose main thrust is to encourage the economic needs of certain individuals, manufacturers, and charismatic leaders goes beyond the ethics of this fine profession and subverts the trust of the public we serve.
In the plight of present economic upheaval, future academic change, and with the erosion of our professional well-being, orthodontics should strive for excellence in performance, service, and results. Unity and pride, coupled with solid intellectual goals, do not require labels to determine who is right or best. The uphill fight for orthodontics to survive as a discipline within which we call ourselves “orthodontists” demands protection and unity from us all.
The use of labels to fragment the unity of modern orthodontics through appliance use or philosophy of practice make us prey to every charlatan who would use us and our patients. The main thrust of our deliberations and concerns should be good treatment versus bad treatment. It is that simple. No labels are needed. Put the records on the table and label yourself.
Harry L. Dougherty, D.D.S.
Advanced Orthodontics
University of Southern California”
(Dougherty H. L.: Read the label before taking, Guest Editorial, American Journal of Dentofacial Orthopedics, Vol. 91, No. 5, May 1987, p.442-444)