Are braces and extractions needed?
The majority of orthodontic problems that are presented to specialist orthodontists require at some stage, some braces on the teeth. Some simple problems may be able to be treated without braces, using plates or similar removable appliances. Braces are currently still the most effective and efficient way to move teeth. They allow for more accurate tooth positioning, more controlled movements and for the vast majority provide a better finished bite result. Although there are various claims in various advertisements/infotainment programs that braces can be avoided by wearing removable appliances at a young age, these views are shared by only a very small number of practitioners; and there are no studies with results to support such a premise. As in all areas of life (whether orthodontics, share investments etc), if it sounds too good to be true, it probably is. And those who claim to have all the answers generally don’t.
Following on from the last paragraph, there are also claims that various orthodontic techniques allow for full non-extraction treatment in all patients. That is, no teeth need to be removed. This is not a new concept and the philosophy has come and gone over the years. With regard to extraction of teeth, the following points should be borne in mind
- Braces provided by specialist orthodontists does not automatically mean four teeth extracted as some advertising relating to early treatment (from 6 years of age) has suggested. Only a minority of patients have teeth extracted; and not all of these need four teeth extracted.
- Orthodontists will treat without extractions if appropriate. Such non-extraction treatment is generally easier and often takes less time. At Ferntree Orthodontics we aim to treat without extraction of permanent teeth in all appropriate cases.
- Early intervention is undertaken if appropriate. Such treatment commences in the mixed dentition stage (meaning some baby teeth still present), often around 10 or 11 years of age. Often additional space for the adult teeth can be obtained at this stage, avoiding the need for extractions later. However, early intervention is not appropriate for all patients. Some are best treated after all the adult teeth have erupted. Apart from relieving traumatic bite relationships with some very early and quick treatment, there is a lack of evidence to support the idea of commencing at 6 or 7 years of age with the intent to avoid braces and extractions later.
- If extractions are recommended this is because after a detailed analysis it is felt this will provide the best treatment result. Our concern lies only with getting the best orthodontic result we can for each individual patient.
- Appropriate extraction plans do not damage the facial appearance. This is a question sometimes posed to us. There are many studies (see section Research, Resources, Links – Evidence based) and without a doubt the consistent finding is that correctly planned extractions do not cause any harm to the facial appearance. We do not defend lack of planning with inappropriate extractions. At Ferntree Orthodontics, as is the case with virtually all orthodontic specialists, all extraction cases involve full braces on the top and bottom teeth.
- Sometimes extractions are recommended and declined by the family/patient. In some cases treatment can still proceed and significant correction and improvement obtained. However, the bite may not be as good as it could be, and there can be an increased tendency for the teeth to return to their initial crooked position (relapse). In other cases, it will be recommended to not proceed with treatment as the result is likely to be poor and/or the overall dental health compromised.
More about extractions
A US national survey found the number of patients needing/having orthodontic extractions to have decreased from the 1980s figure of 39% to 28%. Another report gave the extraction level as 20%. Thus, a figure in the 20 to 30% region would be a good estimate. Australian clinical orthodontic trends do parallel US trends.
The question is not so much the number of patients needing extractions but the reasons for why extractions are required in a minority of patients needing braces. Actual extraction rates can be misleading as it can be influenced by other variables such as geography. Research shows in higher income/socioeconomic areas the threshold for undertaking orthodontic treatment is lower and thus many patients have treatment when the problem is very minimal and extractions are not required. It would be reasonable to say that in Australia there are a greater percentage of the more difficult patient cases in each practice.
The reasons for extractions may relate to:
- The severity of the crowding and crookedness of the teeth. As has been said, you cannot fit a grand piano in a small flat.
- Treatment timing. There are more opportunities to create space with some deciduous teeth present at around 10 and 11 years of age. Although a number of patients (those not too severe) would benefit from such a strategy not all present at this age, and some that do elect not to have treatment at this time then represent again at an older age. Extractions in these older patients would then be more likely. Just expanding the jaws to fit in the teeth in these patients is likely to relapse.
- The patient’s Biotype – what is termed a thin biotype is where the supporting gum and bone are so thin that any dental arch expansion and widening of the area where the teeth are may leave the teeth without adequate thickness of covering bone and gum.
- Decay – Some teeth should be removed due to decay and in such cases what may have been a non-extraction case will be treated better as an extraction case.
- Developmental defects such as hypominersalised molars (defective and poor enamel) which in many cases will have a poor long term prognosis and removal with space closure provides the best result.
- Nature. Some people have inherited missing teeth and this becomes a “genetically determined” extraction case.
- Impacted and ectopic teeth. Teeth may be very unfavourably related and severely impacted making extraction the only viable option. For example, a tooth may be lying horizontal in the jaw and trying to retrieve it would involve complex surgery and may actually damage other teeth.
- Some impacted teeth can cause the roots of neighbouring teeth to resorb and then these damaged teeth themselves may need to be extracted.
- Trauma. Some teeth may have been lost (knocked out or severely damaged) as the result of trauma and the decision is made to have the tooth removed and close the spaces as an extraction case.
- In some cases the burden of care may dictate extractions Although a non-extraction approach may be technically possible, the additional treatment time and cost may make it impractical.
- Stability. For example, studies have shown that attempts to expand or widen the lower jaw will result in relapse – a return to the original status. Thus this is also a limitation in fitting the `lower crowded teeth in. Comprehensive long term retention studies have been done at The University of Washington in Seattle.
- Patients with extreme lip fullness would benefit from the extraction and subsequent retraction of protrusive front teeth giving a more relaxed lip posture.
- Patients hat have what we call bimaxillary dental protrusion may benefit. This is where both the lower and upper teeth are a long way forward.
- Patients with “buck” forward upper teeth in some cases are most easily treated with some extractions. The published clinical research consistently shows excellent results.