In my practice, I treated many “train wreck” patients who had previous orthodontic retraction—often with extractions and retraction resulting in seriously compromised esthetics and function. Two patients in particular come to mind. Both had serious symptom patterns with OSA and pain issues. Both had grown up as chronic mouth breathers, with parents doing exactly what they were told by well-meaning orthodontists. Neither had ever been alerted to the negative consequences of chronic lip-apart posture causing the face to grow more vertically than forward. Both had extraction/retraction orthodontic treatment during adolescence that only added fuel to the fire. One had a pain pattern so severe he openly discussed committing suicide.
Both patients had spent massive sums of money seeking solutions to their problem from multiple doctors in multiple states. Both were tired, in pain, and discouraged. We prepared both orthodontically for surgery to advance both jaws in order to reverse the retractive treatment and bring their soft palates and tongues forward in hopes of opening the airway enough to resolve their OSA. Both got dramatically better. Unlike some previous patients, even the most aggressive forward positioning of the jaws from the surgery did not result in an elimination of the sleep/breathing problems. The physical limitations of these surgical approaches prevented us from getting sufficient forward movement to completely resolve their issues.
In one case, I even re-opened the previous orthodontic extraction spaces subsequent to the surgery in a further attempt to increase the airway even more. Re-opening previous extraction spaces was something we usually did prior to surgery, but for many reasons we felt it better to not do this beforehand for this patient. The suicidal patient improved enough to NOT commit suicide but fell short of his ultimate breathing goals. The other patient similarly continued to suffer from OSA despite an otherwise highly successful surgery by a world-class oral surgeon.
What did we learn from this? Three things were obvious. The first lesson was that surgery is a great solution for many problems, but not all problems. The second, and more obvious lesson, was that retraction should never be done, since resolving the problems with the best available solution could still fall short. The third lesson was the most important: we needed to treat children earlier to help them become 100% nasal breathers so their faces grow forward naturally—and surgery would never be needed.
By failing to hit a home run with these two patients, we essentially learned that we are actually in our infancy when it comes to understanding all the myriad aspects of the airway problem. Humility and conviction to find better solutions were the outcomes from these two patients.
