Dentofacial Orthopedics

Dentofacial Orthopedics: The Modern Miracle of Orthodontics

Information Taken from
"Dentofacial Orthopedics", Community Accent; August 1990, page 27
by S. Kent Lauson, D.D.S., M.S.

"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. The question is, "Is it still necessary to remove all those 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 this century 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?"

The Past

Since the 1940's, traditional orthodontics (braces only with no removable treatment appliances) has taught in university graduate programs the idea that in a large percentage of cases, the removal of certain permanent teeth is necessary. Sadly, although losing much appeal in recent years, the extraction methods still are predominantly taught at universities in the U.S. who teach new orthodontists. Also, these methods are still used by most practicing orthodontists.

In Europe during the 1940's began a movement toward using removable treatment appliances. These appliances, called "functional appliances" concentrated on helping the patient develop proper size and relationships of jaw and facial structures. This is done before all the permanent teeth come in to help eliminate the need for removal of teeth.

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 United States are much better than removable treatment appliances in aligning individual teeth. However, removable functional appliances are much better than braces in enlarging and aligning inadequately developed facial bone structures. Logically, both methods should be used where dental crowding or jaw mismatches occur (overbites, etc.).

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. The first is because of dental crowding. It is important to know that almost never is crowding because the teeth are too large. (It is because the jawbone structures have developed too small.) 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 jawbones very nicely. The second reason traditional orthodontics has called for the removal of permanent teeth is because of a mismatch between the upper and lower jaws and teeth (as in an overbite). In this case traditional orthodontics may have two upper first biscuspid teeth removed so that the upper front teeth can be brought back to match the lower front teeth. In almost all cases, this is not desirable because almost always the lower jaw is at fault and is underdeveloped. To check this on someone with an overbite, observe their profile with lips together as they move their lower jaw from a position biting on their back teeth to a forward position with just their front teeth touching edge to edge. If the second position gives an improvement in the profile, the lower jaw is retruded and functional orthopedics may be desirable. In overbites, the lower jaw gets held back from its normal growth as it is trapped by the teeth in the upper jaw.

Removal of upper teeth to bring back upper front teeth in these cases prolongs the trapping of the lower jaw to restrict its growth, causes flattening of the lip area, increasing the prominence of the nose, could allow jaw joint (TMJ) problems to develop and leaves the lower jaw retruded. Although over 95% of the time the removal of permanent teeth is not indicated (other than wisdom teeth), extreme protrusion or lack of patient cooperation can make the removal of certain permanent teeth necessary.

Proper wearing of functional orthopedic appliances can be a tremendous help in correcting alignment of the jaw structures, to create balanced facial structures with a full, beautiful smile (without unnecessary removal of permanent teeth).

What is typical treatment with this type of treatment?

Typically the orthopedic removable appliance phase will start approximately at age 10. There is excellent growth ahead, patient responsibility and cooperation are generally very good at this age and final permanent teeth will typically be coming in within the next two years. The problems of upper or lower jawbone size and relationship are addressed during this orthopedic phase, which typically lasts from six months to 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 is generally all that is required to finish treatment. Although orthopedic treatment is most effective during the growing years, even many adults can benefit and in some cases, surgery can be avoided with no compromise in results.