Dentofacial Orthopedics,The Modern Miracle of Orthodontics


By S. Kent Lauson, DDS, MS

“I’m sorry, Mrs. Jones, there just isn’t enough room in the bone structure of Johnny’s jaws for all of his teeth. We need four teeth removed. Then we’ll have enough room to straighten all the remaining teeth.” This communication has been heard millions of times in orthodontic offices throughout the United States over the last few decades. The question is, “Is it still necessary to remove teeth to straighten the remaining teeth to get a healthy, beautiful smile?”

Dentofacial Orthopedics – An idea whose time has come.
One of the biggest dilemmas in the profession and perhaps the most debated question in orthodontics in the last hundred years continues to be, “Is it necessary to remove permanent teeth to get the best result with a particular patient in terms of beauty, function and stability?”

In the Past
Since the 1940’s, traditional orthodontics has taught in the university graduate programs, the idea that in many cases, the removal of certain permanent teeth is necessary. Their teaching emphasizes the use of braces without the enhancement of removable treatment appliances. Sadly, although losing much appeal in recent years, the extraction methods are still taught at universities in the U.S. who teach new orthodontists. Also, these methods are still used by many practicing orthodontists.
In Europe during the same time a movement toward using removable treatment appliances was underway. These appliances, called “functional appliances” or dentofacial orthopedic appliances, concentrated on helping the patient develop
Photos before treatment showing narrow arches, protruding teeth and recessed lower jaw

Photos after treatment showing expanded arch forms, corrected bite, and more balanced profile
proper size and relationships of jaw and facial structures. At that time, the European orthodontists, to a great extent, performed their treatment completely without braces while American orthodontists performed theirs without the aid of the removable functional appliances so common in Europe. Braces as developed in the U. S. are much better than removable treatment appliances for aligning individual teeth, however, removable functional appliances are much better than braces for enlarging and aligning inadequately developed facial bone structures. Logically, both methods should be used where dental crowding or jaw mismatches occur (overbites, underbites, etc.). It is the combination of these two methods of treatment that has allowed me to treat even complex cases without removal of teeth or surgery and consistently get beautiful results.

Why are so many teeth removed in traditional orthodontics?
Essentially there are two primary reasons traditional orthodontics has called for the removal of permanent teeth:
1. The first is because of dental crowding. It is important to know that almost never is crowding because the teeth are too large but because the jaw bone structures are under developed or too narrow. Removing teeth in this situation is not the best approach because the patient ends up with straight teeth but smaller than ideal jaw structures. This detracts from facial appearance and can have negative health consequences. Dentofacial orthopedics can handle the problem of constricted jaw bones very nicely, by enlarging them to ideal.
2. The second reason for removing permanent teeth is the existence of a mismatch between the upper and lower jaws and teeth that resulting in an overbite. When an overbite exists, the lower jaw is held back from its normal growth as it is trapped by the teeth in the upper jaw. In this type of case, traditional orthodontics many times has called for the removal of two permanent upper first bicuspid teeth to resolve this mismatch. The upper front teeth are then brought back to match the lower front teeth. This is not a good solution, because the problem is not the position of the upper teeth but the retruded position of the lower jaw. Bringing the upper front teeth back in these cases, does not correct the recessed lower jaw, causing not only the recessed appearance, but a flattening of the lip area and an increased prominence of the nose. Additionally, the lower jaw continuing to be displaced too far back creates a set up for jaw joint (TMJ) problems to develop in the future. This brings out a bigger issue; traditional orthodontic training doesn’t address the importance of preventing future TMJ dysfunctions.
To correct cases with dental crowding and overbites, with proper dentofacial orthopedic treatment, the removal of permanent bicuspid teeth is not indicated over 99% of the time. Extreme protrusion of teeth or lack of patient cooperation can make the removal of certain permanent teeth necessary. However, proper wearing of functional orthopedic appliances can help to correct alignment of the jaw structures, and properly balance facial structures and create a full, beautiful smile, without unnecessary removal of permanent teeth or surgery.

What is typical with this type of treatment?
Typically the orthopedic removable appliance phase will start approximately by age 10. There is excellent growth ahead and patient cooperation is generally at a peak. Also, the final permanent teeth will typically be coming in within the next two years. Patient responsibility and cooperation are generally very good at this age as well. The problems of upper or lower jaw bone size and relationship are addressed during this initial orthopedic phase which typically lasts from four months to as long as a year.
Many options of removable and some fixed appliances are available to select from during this phase based on the patient’s needs. After this phase, another year with braces or Invisalign is effective during the growing years, but even after their normal growth, adults can still benefit. Surgery and teeth extractions can be avoided in almost all cases with no compromise in results.

Advantages of removable orthopedic appliances
1. They are inconspicuous, comfortable and relatively easy to adjust to.
2. They can be removed to clean the teeth and gums.
3. Treatment can be accomplished without tooth removal or surgery in over 95% of the cases.
4. Treatment can be initiated earlier, before all the permanent teeth come in.
5. Fuller, more beautiful smiles, pleasing facial profiles and healthy temporomandibular joints (jaw joints) can be the result.

Photos before treatment showing narrow arches, protruding teeth and recessed lower jaw

Photos after treatment showing expanded arch forms, corrected bite, and more balanced profile

Article by
Denver Orthodontist