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Orthodontics & removing teeth

Can tooth extractions cause sleep apnea difficulty breathing?

There has been no greater controversy over the history of orthodontics than the extraction of permanent teeth. In 1900 the father of “modern orthodontics”, Edward Angle began the principle that God gave us 32 teeth and that is the number we should have. The philosophy unfortunately resulted for some patients in un-esthetic and unstable results. Angle was challenged by Case, who felt extractions were appropriate in some cases. Later, extractions became the norm related to expediency in correcting crowded malocclusion’s. In the late 70’s the pendulum shifted again to non-extraction or even extraction of permanent 2nd molars to avoid “dishing in the face”.

Orthodontic Treatment Goals
Today we have the benefit of studies that give us a better understanding of how what we do affects patients. But most important, that information has allowed us to develop a set of goals to measure how our treatment impacts patient esthetics, stability, health of the jaw joints, periodontium, function and even airway.

The use of 3D CBCT has allowed us to do a much more accurate assessment of the airway as well as the other areas that orthodontics impacts. With CBCT we can measure the airway volume of the oral pharynx, position and morphology of the joints, position of the teeth in bone and other important diagnostic measurements far more accurately than traditional 2D radiographic imaging.

The airway is a relatively new area of study, which has become easier to evaluate with 3D cone beam technology.  Once considered to be a problem for only middle-aged men, we now find airway issues involving women and even young people. While apnea affects a small portion of children it is important to identify these individuals so we can improve their development physically and mentally.

Claims That Extraction of Permanent Teeth Causes Sleep Apnea
Some in the dental community have been making claims that extraction of permanent teeth causes sleep apnea. They claim that extractions cause retraction of the anterior teeth and reduce space for the tongue. But are these claims based on fact or only opinion? Following is but one example of an extraction case that challenges this position. You will see that non-extraction therapy would be quite simple and some could easily argue this is a good example of a case that absolutely should not have extractions. However, I am using this case as a prime example to show the fallacy in such thinking.

Orthodontics & removing teeth

Fig 1. This 13 year-old patient came to our office with a chief complaint of unerupted #18 and poor bite. Facial photos reveal reasonable soft tissue balance with the exception of mild lip strain, lower lip protrusion and a flat smile line.

Orthodontics & removing teeth

Fig. 2. Intraoral photos reveal only mild crowding and inadequate overbite without anterior guidance.

Orthodontics & removing teeth

Fig 3. Lateral cephalometic radiograph reveals proclined incisors and inadequate overbite.

Fig 4. Importantly, the airway volume is moderately narrow at 112 mm2. An Epworth Questionnaire was negative for sleep disordered breathing. Certainly, extractions are not justified in such a case with minimal crowding and a moderately narrow airway. Right? It depends on your treatment goals.

Orthodontic treatment plan: Request extraction of third molars, uncover #18, extract number 4,13,20,29, Full fixed appliances to level and align. Close spaces using minimal anchorage, elastics, detail, retain. Establishing a mutually protected occlusion without extractions would not be possible without extractions.

Treatment Completion:
Orthodontics & removing teeth

Fig 5. Finish of treatment facial photos depict a lack of lip strain, a more balanced lip position and nice smile line. No “dark triangles” noted.

Orthodontics & removing teeth

Fig 6. Intraoral photos reveal a Class I relationship, normal overbite and overjet.

Orthodontics & removing teeth

Fig 7. Cephalogram shows incisors are well positioned in alveolar bone with good overbite and more normal soft tissue and jaw relationships as a result of treatment.

Orthodontics & removing teeth

Fig 8. CBCT Panoramic radiograph shows good root parallelism. Joints are well centered in the glenoid fossa.

Orthodontics & removing teeth

Fig 9. Airway: Most constricted cross section of airway is now 372mm2.

Orthodontics & removing teeth

Fig 10. Facial Smile: left initial, middle mid-treatment, right finish. Note the more relaxed unstrained smile, improved smile line and no “dark buccal corridors”.

Fig 11. Facial Profile: left initial; middle mid-treatment; right finish. Note the more relaxed lips and better balance of the face in the finish.

Fig 12. Occlusion: top initial, middle mid-treatment, bottom finish. The finish has good interdigitation of posterior and good overbite. Obviously, extractions were not needed to align these teeth. However, a functional occlusion would not be possible without extractions.

Fig 13. Comparison of initial and finish cephalometric tracings: only retracted incisors enough to improve lip strain and create enough overbite for normal function.

Airway comparison:

Fig 14. Airway: left: initial, middle: mid treatment, right: final. Ok, so the results meet our goals for joint health, functional occlusion, periodontal health, and esthetics. What about the airway? The airway increased from 112 square mm at the constriction; 322 square mm at mid-treatment; 372 square mm at finish.

This significant change in airway is counter intuitive because there was little crowding. Extractions in this case should have had a negative impact on airway and facial esthetics if we are to believe the argument against extractions. The extractions were used to reduce lip strain, and create a functional occlusion. Few in orthodontics appreciate the benefits of teeth functioning in harmony with the joints in a repeatable, musculo-skeletally stable position (CR), teeth centered in bone and occlusal forces running through the long axis of the teeth, facial balance and relaxing overactive muscles. However, these goals have been demonstrated over decades of studies to improve muscle function. Relaxed muscles should be considered whenever evaluating airways. Even with no change in the airway, this case could not have been finished well without extractions.

Orthodontics & removing teeth discussion
While we should never extract permanent teeth if we can reach all the goals of treatment without them, making a blanket claim that all extractions cause airway constriction is unfounded. We do a disservice to the profession by making claims without proof. In 1900 our founders had to work on conjecture and antidotal evidence. Today we can and must do better!

The argument should not be about removing teeth, but how we close the spaces.
I evaluate the airway for every patient treated. In over 12 years using CBCT, I have yet to find a patient having a smaller airway as a result of extractions. While this is only one case, it was chosen because if the argument against extractions was valid it should have certainly shown up here. Extractions were chosen in order to improve the esthetics and function of the jaws. Without extractions, creating a mutually protected occlusion would not have been possible.

The argument against ever extracting teeth is misguided for several reasons.

First, teeth must be in bone to be stable. Genetics dictates the relative size of the teeth. We can have some influence on the size of the upper jaw.  Moving teeth beyond the confines of the dentoalveolar bone is not stable and it can create periodontal recession and impede function.

Second, the true problem with a narrow airway is skeletal.  Teeth should always be placed in bone. The jaws should be positioned where they function normally and do not block the airway. With the amount of information available today, it is hard to imagine a situation where teeth are taken out and over-retracted. This is borne out by studies that show no loss of airway found with extraction of teeth. The fact is that most people mistakenly identify people who have recessive jaws as those who have had extractions.

 Third, as seen in this case, it is not an issue of extractions but how the space is closed that makes a difference.  Judicious use of extractions improved the esthetics, stability, and function.  With reduced muscle bracing the airway increased by a factor of 330%. While it would be foolish to claim extractions routinely create such improvements, it is no less wrong to believe that well diagnosed extractions cause airway problems.

Orthodontics & removing teeth conclusion
The goals required for successful orthodontic treatment mesh perfectly with the goals of the best restorative dentist in the world. Be it Dawson, Pankey, Spear, Kois, OBI or other world respected teaching centers, all share the same goals for predictable, stable results. As an orthodontist, we are in debt to the work of Doctors Roth and Williams who discovered how to move teeth to accomplish the same esthetic and functional relationships top restorative dentists strive for in a well-treated case.

For more information about Orthodontics & removing teeth contact Roy Orthodontics.

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(757) 471-2900

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(757) 549-1115