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Can adolescent extraction/retraction orthodontics actually cause adult obstructive sleep apnea?

greyham
Eminent Member

Firstly, thanks so much for this amazing forum! I’m a 51 year old male diagnosed with severe sleep apnea after a polysomnograph last year. Up until that point I thought I had chronic fatigue syndrome as I had been ill with severe fatigue, headaches and flu-like symptoms for over 10 years. Until the sleep study, nothing I tried seemed to make me well again and no doctors had any answers.

I came across this forum while exploring orthodontic treatment options for severe sleep apnea. I tried CPAP for two months, which made it hard for me to fall asleep at all and couldn’t imagine (not) sleeping like that for the rest of my life. I also tried throat and jaw exercises and learning to play didgeridoo, which led to a 20% reduction in my AHI from 49 to 39. I now sleep with a SomnoMed Mandibular Advancement Device which has reduced the severity of my daytime headaches to the point where I no longer require painkillers and reduced my daytime sleepiness somewhat.

However, a second sleep study confirmed that it is only partially effective, reducing my AHI to 31; which is still considered severe. It also gives me TMJ pain and makes it hard to fully close my mouth during the day as my lower front teeth now hit my upper front teeth. MAD’s aren’t recommended as a treatment for severe sleep apnea but I experimented with it since my rather conservative sleep specialist didn’t recommend surgery, I hated CPAP, and it was the only other option he really considers. I’m concerned about the long term impact of having my maxilla pulled back every night though, it’s not sufficiently effective on its own, and it’s not really treating the cause of my problem anyway.

I ask myself the question: “What caused my sleep apnea?”. From a risk mitigation point of view, identifying and addressing (possibly by reversing) the cause is likely to be the most effective treatment with the least potential adverse side-effects. Back when I was a biomedical engineer, we called this kind of thinking a “root cause analysis” and it boggles my mind that many medical practitioners either don't adopt this kind of thinking, or seem to give up when they don't immediately find an answer.

When I was 13, I had extraction/retraction orthodontic work to correct what I thought was some pretty mild overcrowding and crooked teeth. I had my four premolars extracted along with an infant tooth which was blocking one of my adult teeth coming down. I had the braces for about 3 years while waiting for that adult tooth to fully erupt and it was very painful much of the time.

I’m not an orthodontist, but I was an engineer and I’m pretty good at logical problem solving. It makes sense to me that if you extract teeth that nature thought were important enough to grow, retract the teeth in front of them, and stick metal wires restricting all the remaining teeth during the period of rapid growth we call adolescence, that’s going to impede the growth of the jaws. Meanwhile, the tongue keeps growing. You're likely to end up with an adult mouth that is too small for the adult tongue. With nowhere else to go, the tongue can only move backwards, blocking the airway; especially during sleep when I'm not awake to hold it forward so I can breathe. Hence obstructive sleep apnea.

This seems blindingly obvious to me; and yet many orthodontists disagree. They often cite this scientific study when doing so: Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review.

Now in truth, I don’t care about the relationship between obstructive sleep apnea and premolar extractions, because that isn't all that happened to me. What I really want to know is whether adolescent premolar extraction coupled with retraction orthodontics causes (or contributes to) adult obstructive sleep apnea. It appears that many orthodontists who say it doesn't interpret the paper as if it were actually answering this question anyway.

I can find little hard scientific evidence to support my hypothesis that adolescent extraction/retraction orthodontics causes adult sleep apnea, aside from a few studies that show that it reduces the airway somewhat. If my hypothesis is true, why didn’t Larsen et al’s paper identify any statistically significant difference between the incidence of sleep apnea between the groups of people who had premolars extracted and those who didn’t?

There are some potential flaws in their research, like:

  • They assumed that people with premolars missing had had orthodontic work done, without confirming this
  • They didn't determine what kind of orthodontic treatment the people with missing premolars had had
  • While they acknowledged that up to 80% of people with sleep apnea are undiagnosed, they didn’t limit the study just to people who have had a polysomnograph to rule it out
  • They didn’t check that people in the group that retained premolars had not had potentially jaw-growth-limiting orthodontic work done nevertheless
  • They didn’t limit the study to people whose orthodontic work was done in adolescence
  • They assumed that the group of people in the study represented the general population
  • They did find that more people with missing premolars had sleep apnea, but not significantly so
  • They didn't consider whether people who retained their premolars had had expansion orthodontic work and what impact this had on their incidence of sleep apnea

Some of these flaws could be explained because the researchers were attempting to answer a slightly different question to the one that I’m interested in, and attempting to correct some of these flaws may well have made the study impractical; but hey, doing really good science is hard. Have I missed anything else here?

The question is important to me because I’m a science guy who likes to have my beliefs and actions backed by evidence. I’d like to know that if I embark on another long, painful and expensive orthodontic treatment that it’s likely to be successful in curing my sleep apnea because I know it is treating/reversing the cause. At the moment I’m leaning towards palatal and mandibular expansion because I prefer the idea of reversing the effects of previous bad treatment, rather than, say, new surgical changes that may just lead to even more unanticipated problems down the track.

Any thoughts?

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Topic starter Posted : 02/12/2019 7:03 pm
ArchTecture
New Member

Hi @greyham

Yes, they can and do cause obstructive sleep apnea.

Retraction/extraction approach in orthodontics is one of those serious errors medicine has made. Many lives have been terribly affected by this narrow thinking in orthodontics, which only cares about occlusion and aligned teeth, ignoring everything else. Ignoring that there is a craniofacial structure that support those teeth and a person behind all of it. That is the quest for alignment and occlusion at any cost, making patients pay a high price at the expense of their own health.

See, not much science or complicated theory is needed to grasp something which is so simple and clear to understand if you have good sense. The body of a growing child is growing all its tissues and bones. Nature wants to expand so that your body reaches your full genetic potential.

Any kind of orthodontic treatment must be in favor of that growth, NEVER AGAINST it. There should never be any form of force vector applied against the natural expansion of the growing body. And that is exactly what some types of headgear do, they put the bones of the face under constant strain and backwards pressure.

If you wanna help a young tree to grow straight, you might place a stake beside it to guide its direction. But you will never want to place a net all over it to prevent its growth and expansion.

Holding back and preventing the bones of the skull in a child from expanding and growing forward with an artificial appliance... Is there a better word to describe it other than sheer TORTURE?

Unfortunately I am one of those people whose health has been seriously damaged by retractive orthodontics. I suffer not only from shallow breathing but I have other symptoms as well, such as constant headaches, fatigue, loud tinnitus and so many others. Some symptoms are so unusual and weird that people won't believe when I tell them they stem from the retraction in my jaws. Not only physical symptoms, but also emotional and energetic ones. It took decades for me to find out the cause because there's barely any science around and most doctors are ignorant to it. You will never suspect your illness was caused by a "treatment".

Also, for years you look at yourself in the mirror every day and you mostly see the front of your face, which can be deceiving and tricky, the front angle is not favorable. If someone sees me upfront with my mouth shut they don't notice there is something wrong with me. It is only when you manage to see your own side profile, either with a picture or an X-ray, that you can have a proper measure of that retraction.

One day I will share my story here, but now my health is very poor and there are some days when I cannot type properly, my fingers won't move right.

I am 41 and I have lived most of my life with pain all over my body. It is something which indeed affects the rest of the body, with different degrees of seriousness depending on a number of factors, including how much your genetic bone growth was artificially deviated from its intended design, position and size by the orthodontic retraction. Some people suffer more, others suffer less. In other words, the amount of retraction to which the bones were submitted by headgear or braces impacts those symptoms and their variety.

I am aligned with the goals of this forum, so I believe that for the ones with less severe retraction, expansion appliances, mewing, posture and non-surgical options should be considered first. Hopefully science will evolve in the direction of even more efficient non-surgical methods. I think this wonderful Great Work forum makes a great contribution to that.

In my case I have talked to some doctors, made a lot of research and considered alternatives. But the thing is that my retraction is so severe that there is no other option other than double jaw surgery for me, and that's what I am heading for. It will be soon because my health is deteriorating every year and I am subject to more serious complications.

This year I had episodes of losing movement and force in my arms and hands. I was able to fight back with some mild thumb pulling, pushing forward my maxilla. Few would believe the drama of this story and how I managed to escape from this and gain some more time. But I know this kind of thing was only for the emergency, to release tension, and it will not solve my problem. I think it is the cranial pressure which is affecting my cervical roots and nervous system. I would have more time if it was only a matter of aesthetics... But a strong measure has to be taken soon in my situation.

There is a website and organisation called Right to Grow, where you can find links to studies, doctors interviews and stories of patients who suffered severely with extraction/retraction. Their homepage 6 minute video explains the subject very well.

Another good source of information on the subject you find at FaceFocused.com, by Dr. William Hang, who treated many patients in this situation and came up with a name for this: E.R.R.S (Extraction, Retraction, Regret Syndrome). Obstructive Sleep Apnea is one of the most classic symptoms.

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Posted : 06/12/2019 11:20 pm
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greyham
Eminent Member

Hey @archtecture,

I'm sorry to hear what you're going through. That sounds like hell. I also get a lot of nervous system problems which I now think are caused partly by the lack of oxygen and sleep disturbance and also by being forced to habitually hold my head forward to keep my airway open, thus putting constant tension on my spine. My most debilitating symptoms are headaches, anxiety and chronic fatigue. 6 months of CPAP has improved these a little, but not completely. I saw an ENT who does double-jaw MMA surgery and was told I wasn't a candidate, so I'm now about to start treatment with a DNA appliance in the hope that it will liberate me from CPAP and ultimately restore my health. If it doesn't work, I could always get a second opinion on MMA surgery after I've done as much palate expansion as possible.

I appreciate that you've been told that your retraction is so severe that there is no other option other than double jaw surgery, but have you considered trying some form of palate expansion first to see if the experts are really correct? One ENT who I was referred to because he is supposed to THE expert on the nose in my city told me I had nasal airway resistance and needed a turbinate reduction. When I asked whether palate expansion improved nasal airway resistance, he denied it; despite masses of evidence that it does. He maintained this position even after I sent him quotes from 27 papers showing that palate expansion improves nasal airway resistance. I got a second opinion from the ENT who assessed me for MMA, and he said my turbinates were fine. So we can't always trust what we're being told by medical experts. Even if you don't get a total cure, palate expansion may improve your symptoms somewhat and set you up for better results from MMA later. I read some research showing that DOME prior to MMA gets better results than MMA alone, and even MMA, despite it's impressive success rate, can relapse as we age. I have heard that palate expansion isn't possible/advisable after MMA because of the metal brackets they put in during the surgery.

My original question still remans though: The study I cited claims there is no link between our extractions and our symptoms. If their conclusion is in fact false, what can we do to debunk it?

Cheers,
Graham

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Topic starter Posted : 26/07/2020 11:06 pm
toomer
Estimable Member

@greyham

Haven't read the whole study yet, but I have seen the headline before.  I think this is part of what @eneltechy has been trying to push against, with her research and data collection.

I'm wondering about their study though - so like 9% with all their premolars had OSA, and 10% with four premolars missing had OSA.  Perhaps not statistically significant.

But, they may have only been testing for OSA.  UARS, which Christian Giullemant created a diagnosis for in recent years, requires specific testing for RDI ... and I think the AASM has only provided guidance on how to score RDI in the last couple years.  We're only now getting home sleep test kits like the WatchPAT-1 which can (supposedly) really measure RDI.

UARS doesn't lead to the oxygen desaturations that OSA patients have.  UARS patients - by definition - typically have very low AHI scores (certainly under 5).  But those constant respiratory disturbances fragment sleep all night, so you suffer some of the same effects.  And UARS patients typically have a high, vaulted palate based on Dr. G's initial definition as I understand it.

So it could be correct that extraction/retraction orthodontics has not statistically contributed to OSA.  But now that we have a clinical definition of UARS and a means to test it, another sample would probably be worthwhile -- I wonder if some of the same authors of that paper would be open to trying to re-run the same study by shipping the same candidates they previously tested some WatchPAT-1 home test kits...

EDIT: I have now read the study a bit further.  It seems like this is only retrospective, just reviewing existing paperwork ... which would seem to indicate that they did not actively test people by putting them through PSGs as a part of the study?  That would make sense on some level, because that would be somewhat expensive.  But given how many people have OSA but don't know it (or are actively ignoring it, like I did for 20 years) really skews their methodology IMO.  I am absolutely someone who would have shown up in their records as "confirmed premolar extractions, no sign of an OSA diagnosis" if their study was done any time from the mid-90's until 2018.  And yet, here I am with severe OSA.

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Posted : 27/07/2020 8:52 am
greyham
Eminent Member

@toomer

Yes, that's my understanding: they were just using existing records and didn't even contact any of the patients to confirm their assumptions. The patients with OSA in their cohort had already been diagnosed with PSGs. It does sound like you're a good example of someone who would have slipped through the cracks in their methodology.

Unfortunately, doing really good science on this is prohibitively expensive due to the time frames involved, and probably unethical. I doubt you'd even get approval for John Mew's identical twin studies these days; and yet they get criticised for having too small a sample size. I fear this study is going to be cited by extraction/retraction orthodontists who don't want to acknowledge the damage they've been doing and resist changing their ways. I saw one video where John Mew lamented realising that he had actually been harming his patients by performing extractions, and I got the impression this had a big impact on him and his feelings of guilt may have been why he worked so hard to educate other orthodontists about the importance of practicing expansion rather than extraction/retraction.

Anyway, I'm preaching to the converted so I'll leave it there. 😉

Cheers,
Graham

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Topic starter Posted : 21/08/2020 3:49 am
toomer
Estimable Member
Posted by: @greyham

@toomer

Yes, that's my understanding: they were just using existing records and didn't even contact any of the patients to confirm their assumptions. The patients with OSA in their cohort had already been diagnosed with PSGs. It does sound like you're a good example of someone who would have slipped through the cracks in their methodology.

Here's what's kind of damning to consider, though.

So they had ~5,000 patient records overall, and about 500 had an OSA diagnosis somewhere in their medical claim history.  And so they looked "forward" from the 5,000 to the 500 to see if there was any statistical discrepancy in terms of orthodontic extractions v. OSA diagnosis.  And there really wasn't.

Ok.

Now, since you have all of this data available - why not do the "reverse" analysis as well?  Start with the 500 with confirmed OSA diagnosis, and then look "backwards" to see how many had orthodontic extractions.  If the "it doesn't make a difference" theory is true ... then there should have been about 250 in the group that had orthodontic extractions, and 250 in the group that didn't.  Give or take a handful.

But the authors of the study didn't think to do that additional analysis.

I mean, that's such a basic idea ... it really makes one wonder whether they were trying to get to a particular outcome.  I don't work in the medical field, but even I can come up with an idea about "maybe if you analyze the numbers in multiple directions, they should be roughly the same?"

I don't want to ascribe ill intentions to the study's authors ... but it really is an astounding oversight.  And unfortunately, things like this then become "gospel" in the orthodontic community.

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Posted : 21/08/2020 6:10 pm
greyham liked
greyham
Eminent Member

@toomer just kindly pointed me to this recent publication of a case report of a pre-molar extraction victim who developed severe OSA, which cites Larsen et al's study with a mild critique, saying:

For example, Guilleminault et al[13] are of the opinion that hypodontia, congenitally missing teeth and tooth extractions are associated with an increased risk of developing OSA. In contrast, Larsen et al[14] undertook an epidemiologic survey and reported that there was no difference in the prevalence of OSA in patients that had premolar teeth extracted for orthodontic reasons and those that did not. However, no sleep studies were undertaken in that survey and it’s possible that many cases of OSA remained undiagnosed in that study.

The paper goes on to suggest that "recapturing extraction spaces appears to help in the amelioration of severe OSA".

Also, Karin Badt just pointed me to Orthodontic Therapy and the Airway – An AAO White Paper Review which also critiques Larson's study:

It is currently estimated that 80-90% of OSA patients are undiagnosed. Larsen's paper states because the subjects all have insurance, they would expect physicians would note the symptoms and get them a sleep study and diagnosis.

There is absolutely no evidence to support that assertion and the existing evidence suggests just the opposite. From pediatricians to primary care, physicians are not diagnosing apnea effectively. The conclusion of the article should be extraction and non-extraction individuals are underdiagnosed at almost the same rate.

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Topic starter Posted : 19/07/2021 4:59 pm
toomer
Estimable Member

@greyham

Well summarized.  TL;DR - the famous "Larsen study" which seems to defend the orthodontic industry's position ... turns out to be utter garbage.

If I were insured by the company Larsen got the data from, I would have been one of those anomalies.  I'm a 4-bicuspid extraction case.  I was first told by a partner in 1996 "sometimes you stop breathing in your sleep" - which I promptly ignored for 2 decades.  Larsen would have counted me as proof that bicuspid extractions do not cause OSA... which would be a faulty assumption to make, given that I did - in fact - have OSA.

I tell you what @greyham ... you, me, and Karin ... with nothing more than a few hundred donated WatchPAT-1 tests ... the three of us could run a better global study than Larsen did.

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Posted : 26/07/2021 10:10 pm
greyham liked
greyham
Eminent Member
Posted by: @toomer

I tell you what @greyham ... you, me, and Karin ... with nothing more than a few hundred donated WatchPAT-1 tests ... the three of us could run a better global study than Larsen did.

lol. They've set the bar pretty low, so it wouldn't be that hard.

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Topic starter Posted : 26/07/2021 10:55 pm