The impact of McNamara’s¹ article on the profession was less than a pin drop at a rock concert.
The “functional orthodontic revolution” of the 1980’s in the U.S. featured attempts to develop the mandible forward, but came and went without significantly impacting the way orthodontics is practiced. This “revolution”, led largely by general dentists attempting to “grow the mandible” did not escape the scrutiny of academia. Indeed, Dr. Lysle Johnston,² former head of the Orthodontic Department at the University of Michigan, found no difference in overall results in patients treated with “functional” appliances vs. headgear/fixed appliance treatment. He noted that both groups were likely to conclude treatment with a “moderate midfacial dentoalveolar retrusion”. One might assume that this conclusion would motivate academic leaders to research ways to achieve better facial balance, but several years have passed with apparently no such movement. With a litigious society bent on eliminating all risk in life, we have warnings on Starbucks cups telling us that coffee is hot and on gasoline pumps telling us not to drink gasoline. Combining that mentality with the society’s obsession with esthetics of the entire body one might imagine a future requirement of an Esthetic Impact Statement from orthodontists. If the orthodontic profession is truly concerned about esthetics isn’t it fair to tell parents, in terms they can understand, that a very likely outcome of any orthodontics will feature their children having faces “with both jaws recessed from an ideal position”? Such a warning might also include that some patients will end up with “both jaws severely recessed from an ideal position”. Is it better to do this voluntarily or to wait for patient lawsuits to force the issue? But many in society would protest that beauty on the outside is unimportant and only beauty on the inside really matters! Let us now discuss what is on the inside!
The airway is on the inside, and with it what seems to be emerging as the key to health. With OSA seeming to become a central issue in cardiovascular disease, stroke, and cancer it is hard to fly below the radar any more. Remmers’ presentation only touched on the critical role that dentistry might take in health care using oral appliances to address snoring and OSA. His work strongly suggests that OSA is structural and recessed maxillas and mandibles reduce the airway and cause the problem.
As Prof. Johnston noted, many children will have recessed maxillas and mandibles following orthodontic treatment. Is there any way to avoid the conclusion that our post-orthodontic patients are more at risk for OSA with both jaws recessed? It only gets worse considering Mew showed both jaws continuing to fall back during life (further increasing OSA risk) unless oral posture is corrected. If parents understood the serious risk of cardiovascular disease, stroke, and cancer associated with OSA (thoroughly discussed at the AACP meeting) would they not demand a better result? If the profession has no solution should it not at least provide an Airway Impact Statement warning that patients with recessed jaws are more at risk for OSA? Current informed consent forms tell patients that they might have root resorption during orthodontic treatment, but I’m unaware of anyone making a premature exit from planet Earth from shortened roots. People are dying daily of OSA related problems.
John Mew has developed a solution for the facial imbalance, and it has been there for years for those who are interested. Dr. David Singh of the U. of Puerto Rico has used his Morpho-Studio Program to analyze records of my patients treated with Biobloc to prove that a more forward direction of growth of the face can be achieved with Biobloc. More importantly, Singh’s research (as yet unpublished) shows a dramatic, clinically significant improvement in the airway with this treatment. Having privately presented this information recently to an orthodontic department head, offered to teach it, and proposed significant research projects in this area he responded that he was unsure that a bigger airway was necessarily better! The outlook for meaningful change in that department appears rather grim at the moment.
Exactly where is the orthodontic profession on this subject right now? The failure of patients to cooperate with either functional appliances or headgear wear has led to a proliferation of “non-compliance” approaches. The upcoming AAO meeting in May will feature 19 speakers on the ultimate instrument of “non-compliance” - temporary anchorage devices (TAD’s). These are mini-implants to serve as immovable anchorage. If the pattern shown in the literature concerning their use is any indication, most of these speakers will be showing how to get more retraction of the front teeth with no anchorage loss.