Steven Jay Bowman, DMD, MSD

It is truly unfortunate when misinformation is disseminated to the unsuspecting and trusting public.  Certainly, matters of professional opinion can differ but are best resolved by professionals and one of those methods is through the use of research and peer-reviewed publication.  Making brash, bold, and unsubstantiated claims and generalizations not based in reality, especially in this type of forum where patients may use the information to make treatment decisions is at best, simply unbecoming of a learned profession.  Statements such as "creates excess," "often cause," "are the result," "primary reason" attended without in fact are a disservice by the uniformed to the layperson.  

The prospective patient is searching for information to make an informed consent and would be best served first suggesting that they personally return to a licensed orthodontic specialist or two to gather this information; not propagating myths. 

First, "Damon" is a name brand of braces and there are hundreds of brands.  It has nothing to do with preventing extractions or reducing TMD.  There is no evidence.  It is marketing. 

In regards to your question, there is a plethora of data on the question at hand.  Doing a simple PubMed search using keywords is a good place to start.  Also contacting the NIH for their position white paper (i.e., paraphrasing "orthodontics is not a cause or cure of TMD (including the extraction of premolars") might be useful.  To give you a start, below is the abstract from a peer-reviewed paper (one of numerous others) that provide with the answer:  Extracting premolars (a procedure that provides substantial improvements for patients that need them) is not a risk factor for TMJ (PERIOD).

Orthodontic risk factors for temporomandibular disorders (TMD). I: Premolar extractions by Kremenak, Kinser, Harman, Menard, Jakobsen, American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 101, Issue 1, Pages 13-20, January 1992.

"Concern about claims that premolar extractions may put patients at risk for temporomandibular disorders (TMD) led to this study. We report first findings from a longitudinal study of orthodontic patients begun in 1983. By using the methods of Helkimo, we collected TMD data before initiation of orthodontic treatment, between 0 and 12 months after debanding, and 12 to 24 months after debanding. Analyses related Helkimo scores with premolar extractions in 65 patients for whom orthodontic treatment had been completed. Twenty-six patients were treated without premolar extractions, 25 had four premolars extracted, and 14 had two upper premolars extracted. Tests for significance of differences between mean Helkimo scores were conducted for the nonextraction group compared with the extraction groups, and between pretreatment and posttreatment Helkimo scores for each group. Results included: (1) no significant intergroup differences between mean pretreatment or posttreatment scores, and (2) small but statistically significant (P < 0.05) differences (in the direction of improvement) between mean pretreatment and posttreatment scores for both the nonextraction group and for the four premolar extraction group."

Before the teeth have the chance to move further, make sure to visit with your orthodontist to ask his or her opinion.  Don't wait for additional changes as small discrepancies may be resolved with a simple retainer adjustment.  Good communication with your doc is key.

It is important that there is clear communication with your orthodontist about what can and cannot be achieved.  Looking at the pictures, it seems that some mild improvements might yet be possible by wearing your custom tooth positioner 24/7 for a minimum of one week; "chewing it" regularly during the day.  Since you've moved on to Hawley retainers, returning to the positioner should be under the supervision of your orthodontist.  If the retainers are being worn 24/7 and no improvement noted, then it may be time to bite the bullet and opt for some minor re-treatment with braces if suggested by your doc.

You have received a number of excellent answers from other practitioners.  Final lip position is not strictly a function of whether extractions are performed.  In fact, more protrusive lips can be produced even with extractions depending upon the biomechanics employed and the goals determined for treatment.  If retraction of the teeth to reduce protrusion is desired, then some degree of lip retraction is likely to accompany the teeth.  There have been a number of studies attempting to determine the predictability of the amount of this lip change that have demonstrated varying success.  In 2005, workers from Brazil and U.S. published a study of upper first premolar extraction patients and again found only mild predictability, but on average there was about 0.7 mm of lip retraction for each 1.0 mm of front tooth retraction.  Interestingly, enough, these changes are most often determined to be esthetically pleasing in these types of situations where patients desire reducing the protrusiveness of their front teeth.

Dr. Waxler's answer is correct; however, the most important message is clear communication.  You need to insure that you get your questions answered at your appointment.  If you are confused, then get clarification from an orthodontic assistant or even the receptionist.  If they don't have the answers, they will get them from the orthodontist.  Don't leave without your question answered.  

Adding orthodontic elastics to Invisalign aligner trays and/or to brackets or buttons attached to specific teeth is a viable option for the correction of certain issues.  With that said, there are certainly some limitations.  Some overbites (or overjets:  protrusion of the upper teeth) may be too severe to correct with only elastics.  Consequently, it is important for your licensed orthodontic specialist to determine the difficulty level of your particular situation.  

Ceramic or crystalline braces are made of materials that are harder than your own enamel.  Consequently, if clear braces are placed on the lower front teeth and the edges of the upper front teeth contact them, then there is a potential for damage.  Specifically, the upper teeth could develop wear marks or grooves where they contact the lower ceramic bracket.  It is for that reason that orthodontists elect not to place clear braces on the lower teeth.  It is imperative that you consult with your licensed orthodontic specialist for their opinion about your specific circumstances.

Wearing elastics on the outside of the aligners is most common useage and yes, they may make the trays slightly more noticeable, but by whom?  Most often the things that you are aware of are not noted or of concern to the public.  If they are noticed, they are likely aware you are doing something special for yourself by wearing something to improve your smile.

It is certainly possible to hook-up elastics on the "tongue-side" of the teeth.  When you speak, those elastics are still going to be seen, stretching from top teeth to bottom, so I'm not sure this solves your issue.  In fact, adding "buttons" or notches for the elastics on the inside of the trays may be more uncomfortable and irritating to your tongue.  You may wish to ask your orthodontic specialist to "notch-up" a pair of your last aligner trays to give it a try before altering new sets to find out you can't tolerate this "hidden" approach.  

Most importantly, the concept of any orthodontic treatment being absolutely and completely inconspicuous is somewhat unrealistic and actually ruins some of the fun.  You are obviously excited to be able to improve your smile, that enthusiams can be contagious and other folks may elect to do the same for themselves just from your influence.

The bubble you refer to fits over an attachment that was placed on your tooth that was prescribed and designed to specifically move that tooth.  Discussing the use of attachments in Invisalign should occur before treatment begins as these adjuncts are quite typical, in fact, many times multiple attachments are required.  Although these bumps or bubbles may be visible to you, most folks looking at your smile are unaware of them.  If they are noticed, you can inform those that comment that you're improving your smile with Invisalign aligners and that is part of the treatment.  You could continue that you are fortunate that you are not wearing traditional braces as they would be even more noticeable.  Communication with your licensed orthodontic specialist is key in achieving the results you desire.

Changing orthodontists in the midst of treatment is typically termed a "transfer" between practitioners.  If the change is made strictly for location convenience, then the costs for travel and time must be outweighed by the costs involved in the transfer.  If you are pleased with the services of your current licensed specialist, that may be far more valuable than the unknown of a new office and orthodontist.  Saving a few dollars on gas or minutes in transit over a two year period may not cover the costs of "regret" if you find you're displeased after you transfer.