Upper bicuspid extraction......often the worst treatment in all of orthodontics
William M. Hang, DDS, MSD
OrthO2Health - Two Mentorships with William M Hang DDS MSD
What prompts a 40ish year old woman from Switzerland to spend one hour on the phone with me in a long distance consultation? How bad can things be for someone to consider flying from Zurich to Los Angeles perhaps 10 times to reverse treatment which she thinks has caused both negative esthetic changes and functional issues (headaches, neck aches, backaches, ringing in the ears)? This is a story I’ve heard many times from many different patients over the past 35 years, and it is so predictable.
This woman has a facial skeletal pattern that all the most attractive models have. Her face height is not long, and the border of her lower jaw is more horizontal rather than vertical. Her cheeks are well developed. Her lower jaw is slightly recessed, but her upper teeth were actually slightly too far back in her face even though there was a little space (overjet) between the upper and lower teeth.
To orthodontists with traditional training the upper teeth need to be retracted to meet the lower teeth even though the upper teeth clearly do not protrude relative to the nose, cheeks, and forehead. The upper right and left first bicuspid teeth are removed which instantly makes a 7 mm. gap in the smile. Braces are used to retract the front teeth in the face. In many cases about 3-4 mm. of space closure is completed and the space between the upper and lower front teeth is closed. That means that the front teeth come together at the same time as the back teeth. Often about 1/2 of the extraction space remains at this point, and no one wants to smile with a 3-4 mm. gap behind their eyeteeth. The orthodontist continues to close the space to eliminate the gap even though the front teeth are already fitting tightly. As this further retraction continues the upper front teeth begin to hit PREMATURELY on the lower front teeth, and the lower jaw is displaced backward.
This process of pushing the lower jaw back results in the upper portion of the lower jaw (the condyle) being pushed back too far....into the area right in front of the ear. Ringing in the ears can result from this. The teeth cannot be made to come together without pain because the lower jaw is being forced back into a position that the muscles do not want. The muscles pay a heavy price for this. The lower jaw must be postured forward all the time. This changes the neck posture, produces a tilt of the head, and frequently back problems result. As they say, “The head bone’s connected to the neck bone. The neck bone’s connected to the backbone...”.
The functional issue of the pain pattern can result in someone being so miserable that they can barely function eating and talking normally. It isn’t funny, and it is preventable by not doing this kind of treatment in the first place.
Insult is added to injury when the patient (like this Swiss woman) see their lips falling back, getting slightly thinner, the cheeks caving in as the dental arch narrows, and the face height getting slightly longer.
I’ve heard this story probably hundreds of times over the past few decades. Does that mean that there are a lot of crazy patients who don’t know what is going on for them? I don’t think so. It means that they are giving the orthodontist a VERY DETAILED MEDICAL HISTORY. Every doctor must take a medical history before treating anyone, and the doctor generally believes the patient when they write the details of that medical history in the record. Why is it that so many orthodontists don’t believe the patient when they relate these very specific details of a symptom pattern? Is it possibly because the symptoms were brought on by the treatment they initiated? When I suggested that this patient discuss all this with the orthodontist and ask to have the orthodontist reopen the spaces I learned that she already had done this...and the orthodontist said the treatment that had been accomplished did not cause the problem and the spaces cannot be reopened. The orthodontist was wrong on both points. The symptom pattern is related and the spaces can be opened. This patient is now contemplating traveling from Switzerland to LA to have us reverse this treatment! This is another classic example of Extraction Retraction Regret Syndrome? or E.R.R.S.?.
What is the take home message from this story? Don’t retract!!
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5 年I had four teeth extracted in my childhood (2 at top, 2 at bottom) + braces, had really serious TMD (really strong vertigo, face/ears pain and much much more ;) ). Year ago I was unable to keep both of lower wisdom tooth (damaged, errupted in really bad way - had extraction surgery) - but I was able to keep upper one (was painful, they did not have space but after time they erupted - perhaps during expansion process). Now, ~15 years later I am treated again with palate + lower jaw expanders with/followed by braces. Treatment involves jaw?physiotherapy, posture training and a lot of things I have no idea about :) I also had to fix my crooked nasal septum as mouth breathing seemed to be the roots of all evil. After few months my TMJ seems to dissolve, much less/no more forward head posture and general teeth/face width/airflow/life quality improvements (but that is just beginning).I am not related to orthodontist field but according to my personal case and "modern knowledge" I believe tooth extraction should be allowed (by law - because what ordinary people know about orthodontist/orthotropics ? - nothing) only when there is life danger (perhaps like strongly damaged roots?)?
Attorney | USAF | TS/SCI
6 年Are implants the only option to correct the effects of extraction?
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6 年my situation is different in that it was a camouflage situation at age 13 instead of developing the palate...or offering/suggesting orthognathic (none of which were presented to my parents as an option). now after surgery well into mid adulthood...then re opening of spaces on top and then repeated revision surgery with total tmj replacement, tonsilectomy 2 sinus surgeries...and multiple rounds of braces... i was still having significant sleep apnea..which after having the maxilla re widened on the right side was some better. it has been discovered i have chronic sinusitis...now osteitis (right maxilla) which causes upper airway resistance. everything has to be just right for me to sleep without it happening..which means what i eat, how i brush the teeth, where i live as in higher humidity helps... and the type matress...et. keeping the upper airway inflammation down and trying to keep the sinuses with less inflammation is now the focus..people with the long face issue who have the extractions rather than the proper treatment of expanding and or surgery end up with life long issues..that will never fully go away. removing the tonsils alone....orthognathic treatment helps but in some of us the issues remain..(in my case i have discovered probably have( right deformational plagiocephaly) which was not picked up on. my oral surgeon and my ENT agree this is most likely the case..i have all the characteristics of it. it may be that nothing would have made much difference..in my case and there may be a small percentage of patients with craniofacial issues that will live with it the best they can through life..however surgery helps tremendously with self esteem and appearance...as well as chewing. i'm definitely not a fan of bicuspid extraction...espeicially for a skeletal defect...i now after surgeries and therapy keep my tongue in my palate...up at the top something i never was able to do or comprehend......and yes even with all the surgery, re reopening et tongue .. still probably causes issues at night. its to the point im on the east coast and my husband on the west bc i need humidity...which helps keep me from mouth breathing and lips together...less dry mouth and sinus...less sinus infections/antibiotics. as far as im concerned bicuspid extraction only camouflages underlying medical or skeletal conditions making proper treatment discovered way late in life as in decades...and as in the situation of the swiss woman..basically sounds like she had not much wrong with her..however the treatment unecessary bicuspid extractions created issues in health and appearance ..very unnecessary when the person has already a good foundation.....
Healthcare Services Manager experienced in strategic planning, medical practice startups, medical device sales and sleep test program implementation, medical billing, training and office administration.
7 年Something else to consider here is the negative effects on the upper airway. Tooth extractions, while they are great in providing space for alignment, the shrink tongue space (14mm of arch circumference in this case). This causes the tongue to retrude, which in turn aids in collapsing the upper airway, which leads to incremental snoring and possibly sleep apnea. The base of the tongue is one of the main contributors to a restricted airway. I wonder if Dr. Angle would have reconsidered his recommendations had he known what we know about Sleep apnea today. Any thoughts?
Dental Coach and Educator, DMD at Comprehensive Dentistry
7 年It's true. Making the patient's mouth small is not attractive