Will braces solve overjet/overbite without extraction?

Question

I'm a borderline case for extraction and I want to avoid it as much as possible due to possibility of ruining my face. I have a small overjet (5mm) and a bit of overcrowding at lower teeth. Will braces alone solve this or will I have to extract 4 teeth, which I feel is a bit extreme? Cause after aligning my teeth, Im told my teeth will move more outwards which can worsen my protrusion. Thanks!

Robert Waxler, DMD, MS · Answer

Premolar Extractions Controversy

There is probably no facet of
orthodontic treatment that has caused as much controversy as the decision to
extract, or not to extract, permanent teeth: and more specifically, whether to
extract four premolars or to “develop” room for non-extraction treatment.

Besides the obvious reasons of avoiding the trauma and
expense of surgery, and the desire to preserve permanent teeth; other alleged
negative sequela, such as TMD problems, flattened facial profiles, and “dark
buccal corridors” have contributed to the premolar extraction controversy. Like
a pendulum, the popularity of premolar extractions has swung back and forth,
between the extremes of non-extraction at any cost and “routine” extractions to
achieve arbitrary cephalometric norms.

Some of the factors we consider
are:

When dealing with a fairly “normal” orthodontic
     problem (no gross asymmetries) the decision to extract four
     premolars is straightforward although often not easy. It is impossible to
     extract less than a whole tooth, and usually the extraction of a tooth on
     the left requires an extraction on the right to balance the midline.
     Likewise, lower extractions usually require upper extractions (and visa
     versa) to prevent excessive overjet or underbite. These constraints
     normally lead to extraction of four first premolars or to treat as a
     non-extraction case.. There are times when upper premolars only, a single
     lower incisor extraction, molar extraction, or interproximal enamel
     reduction (IPR) are appropriate but, in general, the decision for
     extractions is often framed around “4-bi’s”. In other words…even
     though the amount of crowding is a simple variable (from slight to very
     severe), the “correction” is an all or nothing decision (4 teeth
     extraction or no extractions at all).

Given the usual all or nothing nature of the
     premolar extraction decision, it is no surprise that different
     orthodontists often appear to have conflicting treatment plans for
     the same patient. The reason is not that they see very
     different problems or have radically different philosophies of treatment,
     but rather that each doctor has a different line in the gray area between
     extractions and nonextraction. Two treatment plans that appear very
     different can both be based on a similar analysis of the patient’s
     problem, but end up with very different treatments due to the black and
     white nature of the decision making process.

It is important to understand that in borderline
     cases there are no correct or right answers. Both treatments
     performed by competent orthodontists would produce a good result, but
     neither is perfect. Each option would have pros and cons, and
     orthodontists and dentists could (and do!) spend endless amounts of time
     debating which option is “right”.

We try to avoid extractions as much as possible, but extractions should be considered when
     esthetics and stability call for it. 
     Truthfully, almost any patient can be treated without
     extractions and, often, it is the technically the easier way.  This is the reason that the weekend orthodontic
     courses, aimed at general dentists, almost always stress nonextraction
     treatment.

Where there is a conflict between
     facial esthetics and dental stability, it is our judgment to favor
     esthetics.  This is not to say that patients with
     flat facial profiles and extreme crowding should be treated without
     extractions, nor that patients with full profiles and large tongues should
     have teeth extracted, but rather that esthetics should be the primary
     determinant of treatment in any borderline situation.  In these cases it is very important that
     the patient understands the necessity of long-term retention

Contrary to the beliefs of many nonextraction
     proponents, good scientific studies (evidenced based) done on TMD and
     orthodontic treatment fail to show any correlation between the
     development of TMD type problems and the extraction (or
     nonextraction) of teeth.  All
     dentists can remember patients who develop TMD problems after extraction
     treatment and, if you feel there is a correlation, you will fixate on
     these patients.  Statistically, you
     are just as likely to find TMD problems in patients treated nonextraction
     or, for that matter, patients who never received orthodontic treatment at
     all.

Scientific studies have also shown that well
     treated extraction cases do not adversely affect facial profiles.  Again, it
     is easy to visualize patients with flat profiles who have had premolar
     extractions.  Assuming a good
     treatment decision, these patients would have had a flat profile even if
     they never had treatment (and an extremely unstable dental alignment if
     they had been treated without extractions). The truth is: tight facial
     structures (flat faces) lead to crowding, which leads to extraction rather
     than extractions cause flat faces. As a matter of fact, the most dished in
     and flattened faces often belong to those patients whom we have treated without
     any extractions. Like the TMD controversy, negative esthetic effects
     attributed to extractions fall into our favorite logical fallacy “post
     hoc ergo propter hoc” (after this therefore because of this).  Other studies have also shown that dark
     buccal corridors and a narrow smile are not “caused” by premolar
     extractions.

A good selling point for premolar extractions can
     be a patient with moderate crowding and well-formed and positioned third
     molars.  Treated without premolar extractions
     this patient usually needs third molars removed. Extract premolars, close
     some of the space by mesial movement of the posterior teeth, and hopefully
     the thirds can erupt and be kept—an exchange of four small, easily removed
     teeth for four molars that would be difficult to extract. Unfortunately no
     guarantee can be made that the thirds will always come in with enough
     room.

There seems to be a great deal of confusion about
     early expansion treatment (AKA arch
     development or growth
     modification).  There is a
     important difference between expanding a constricted upper arch to match a
     normal lower arch (OK) and significantly expanding both arches in a
     patient whose arches may be narrow, but are in a normal transverse
     occlusal relationship to each other (not OK).  Although it is possible to upright
     lingually verted lower posterior arches (which may have collapsed in, to
     compensate for a narrow maxillary arch), it is not possible to expand the mandibular
     basal bone, as there is no suture to distract as in the maxilla.  Of all the inviolate “facts” of
     orthodontics, one of the most established is the stability of the lower
     inter-canine width.  Expansion
     beyond the original width is almost a guarantee of collapse and
     recrowding.

Every decade or so a new “magic bullet” comes
     along promising the ability to create space and avoid extractions or
     unstable expansion.  The latest
     iteration of this is the Damon&trade; orthodontic bracket with its
     manufacturer’s promise of extremely light forces that “grow” more room
     than regular braces.  As usual, no
     good science backs up these claims!

In an attempt to avoid first
premolar extractions, various alternatives can be considered:

oExpanding the arch, especially in a flat-faced
individual, is often preferable to extractions, with the understanding this is
an unstable correction and perpetual detention will be needed.

oFor
patients with a good posterior occlusion, a good upper arch with relatively
small upper incisors, moderately severe lower crowding, and minimal overbite,
the extraction of a lower incisor can be considered. Extraction
of an incisor should be evaluated very carefully, for it can result in an
untreatable problem with excessive overjet/overbite in the wrong individual.

oInterproximal
enamel reduction (IPR)
can provide a moderate amount of room but should be reserved for older
patients. Excessive IPR as an initial treatment complicates the orthodontist’s
ability to correct minor relapses in the future.

oConsider
extraction of second premolars rather than first premolars.
Theoretically, this reduces the amount of anterior retraction when only some
space is needed for crowding and the facial profile is acceptable.  This works best when the second premolars resemble
the first, but large, molar-like second premolars may provide too much room and
small, canine-like first premolars may not work against first molars.

oDistilization
of full arches is very difficult so extraction of third molars or even second
molars to provide anterior room has never been shown to provide significant
space.  With the advent of temporary
anchorage devises (TAD’s) this may become a “new” way to treat
nonextraction…. we’re already trying it!

Bottom line: Extractions are just a tool, not good or bad
in themselves.  Used right, they improve
the quality of treatment, used wrong they may create a poor result. Finally,
ask you self: “what is really the most conservative treatment: extract
some teeth and end up with a stable and functional result for the next 50 years
of your life or, treat “conservatively” without extractions and end up with a
result that will relapse the second you stop wearing your retainers

Will braces solve overjet/overbite without extraction?

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Will braces solve overjet/overbite without extraction?

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