Are there alternatives to having teeth removed for braces?

New patients and their parents usually have the four same questions for me at their first visit. Parents want to know how long treatment will take and how much it will cost. Kids want to know if they’ll have to wear headgear or have teeth removed. In this day and age, there are alternatives to headgear. Are there also alternatives to extracting teeth?

Four reasons teeth are removed for orthodontic treatment
To answer this question, remember why teeth are typically removed for orthodontic treatment: First, to relieve crowding; second, to improve lip posture; third, to compensate for mismatched jaw sizes; and fourth, out of a biomechanical necessity (to allow tooth movement during treatment).

Teeth are removed to create space in crowded mouths
First, in cases of severe crowding, removing teeth may be unavoidable if the size and shape of the underlying bone is just not sufficient. Keeping all of the teeth in these cases would not only make patients look protrusive (teeth sticking out in front of the supporting bone), it may also cause recession (loss of gums) or dehiscence (loss of bone). With mild to moderate crowding, extraction or expansion are both possibilities. Expansion means that the size of the arch is increased by moving the teeth outward. In cases where the underlying bone is sufficient, this can be done with the braces alone. In those where the supporting bone is just too small, expanders may be used to “grow” the jaw bigger. Skeletal expansion is effective in children up until the age of about 16. After that (when the growth plates are fused), surgery may be necessary to reopen the sutures so that the roots aren’t merely pushed out of the bone.

Removing teeth may be necessary to IMPROVE the profile
Second, the position of the lips is influenced by the position of the underlying teeth. If a patient has good lip posture to begin with, care must be taken so that aligning the teeth via expansion doesn’t make them look protrusive. If they are crowded, this may mean the removal of teeth just to keep the lips in their original positions. In patients who already have protrusive teeth or a “full” profile, any expansion will only make the situation worse. Although it may be possible to align the teeth in these patients without removing teeth, doing so may actually make things look worse.

Removing teeth may be necessary for bite correction
Third, in cases of moderate to severe overbite, there are two options for correction. One is moving the lower jaw forward (requiring jaw surgery). The other is scooting the top teeth back. In mild to moderate cases this can be achieved with rubber bands or springs. In more severe cases however, removing upper bicuspids is required to create the space necessary for greater correction. Given the choice between surgery and the removal of two upper bicuspids, most patients opt for the latter. In patients who are adamant against extractions however, jaw surgery is always an option. (Similar choices exist in patients with underbites.)

Removing teeth may be needed to allow necessary tooth movements
The last reason your doctor may recommend having teeth removed is to create the space and forces necessary to move your teeth during orthodontic treatment. Although it may be possible to move teeth without extractions, there are always tradeoffs. For example, one alternative to removing two lower bicuspids in a patient with a mild underbite is to using temporary anchorage devices (TADs). In these cases the orthodontist spends the first year of treatment pushing the lower molars backwards using the TADs as anchors. Once the molars are in place, he then moves the front teeth back to close the space he just created to eliminate the underbite. Had two teeth been removed at the start however, the end result would have been the same and achieved a whole year earlier. Nevertheless, TADs might be used to avoid extractions.

Sometimes removing teeth is the best option
So is it possible to straighten your teeth without extractions? It might be. As described above, there are options. I’m reminded however of a scene from the original Jurassic Park. Dr. Ian Malcolm (played by Jeff Goldblum) looks out the window of the helicopter as they swoop in over the island for the first time. Upon seeing an actual dinosaur, he exclaims “You were so focused on ‘can we do it,’ you forgot to ask ‘should we do it.’” Although it may be possible to avoid removing teeth, it may not always be the best option when treatment time and the health of the teeth are also considered. Ask your orthodontist if any of these alternatives to extraction (expansion, surgery, or temporary anchors) are right for you.

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa in the United States. Dr. Jorgensen’s 25 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor can he select treatment plans for readers. Because he has over 25,000 readers each month, it is impossible for him respond to all questions. Please read all of the comments associated with each article as most of the questions he receives each week have been asked and answered previously. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.