Will 2018 finally be the year when..orthodontists recognize the lunacy of treatment for so called “Bimaxillary Protrusive” patients?

Will 2018 finally be the year when...orthodontists recognize the lunacy of treatment for so called “Bimaxillary Protrusive” patients - particularly Asians and African Americans? 

I just finished presenting a new segment of slides to my Advanced Mini-Residency on the subject of so called “Bi-maxillary (Bi-alveolar) Protrusion”.  It featured many Asian patients and some African-American patients with e-mails from those outside the country and actual records for many whom we are treating.     

I literally just got another e-mail with full records prior to treatment and after treatment from a man in his late 20’s. He was treated in Hong Kong as an adolescent. His long list of symptoms, including fatigue, lack of energy, problems sleeping, etc. prompted me to write this article. Frankly, I’m tired of getting these e-mails and want to put a stop to what I consider the insanity of the treatment. 

In the 1940’s a soft tissue standard in orthodontics became accepted in the US. By drawing a line from the tip of the nose to the chin the fullness of the face was described. Orthodontists frequently call this the “Esthetic Line”. If the lips are ahead of this line the face is generally considered too full or ‘Bimaxillary Protrusive”. There are articles in the literature which describe this literally as a “disease”. (I’m not making this up!) The treatment recommended to flatten the face is removal of four bicuspid teeth and retraction of the front teeth to reduce the so called fullness of the face. In the last decade temporary anchorage devices (TADS) have been added to this treatment to maximize the retraction and eliminate what orthodontists call “anchorage loss” or forward movement of the molar teeth. The point is to get MAXIMUM RETRACTION to produce a maximum flattening or the profile. Now that we have TAD’s we have retraction on steroids!   

In our office we treat patients of all races and note that most Asian noses and African American noses are anywhere from 3-5 mm. shorter than a Caucasian nose! This means that patients of these ethnicities will naturally have fuller looking profiles with all other factors being equal.    

The next part of the insanity in the diagnostic process is the fact that the chin position is almost universally ignored in making this diagnosis. Almost all the cases I see in the literature, those patients who come to my office or contact me via the internet have the chin recessed from the norm by one to two standard deviations. The point is that a line drawn from a recessed nose to a recessed chin will make almost anyone of any race look like their lips are full! These two racial groups are at great risk for this “diagnosis” although many Caucasians also receive this diagnosis and treatment plan.  

Three months ago I received a phone call at 6:20 A.M. on a Sunday from a Chinese woman living in Michigan undergoing treatment for a face the orthodontist deemed too full. She had difficulty breathing which was her reason for this “emergency” call which brought my wife and me out of bed to answer the phone. By 7:10 a.m. she had emailed her pictures of the entire treatment as well as a narrative of her situation. The whole story documenting extractions and retraction was staring at me from the computer screen. This incident is NOT isolated. Three articles in the refereed literature indicate that the airway can be reduced in patients who receive extraction/retraction treatment. The people contacting me from all over the globe are not crazy when they tell me, “I can’t breathe.” The literature agrees that their perception is not wrong!    

Does this happen to everyone undergoing this treatment? Of course not. Having said that, if one cannot predict who will and who will not react negatively to extractions and retraction, is this a prudent treatment approach? As an orthodontist are you prepared to take this risk? As a patient are you prepared to take this risk?