Why would an orthodontist recommend extracting four teeth for crowding, and a general dentist recommends against it?

Hello,

Welcome to icliniq.com.

I hope you are doing well. Crowding is one of the common findings seen in patients. There are various modalities to treat a case of crowding with extraction or expansion or non-extraction with interproximal reduction. Extraction: Here, a certain number of teeth are extracted to create the space, and other teeth are aligned using this space. It resolves the crowding, uses up the extraction space, and teeth are also aligned. Expansion: In certain cases, we prefer to go for expansion rather than extraction wherever possible. Certain factors, such as the age of the patient, the amount of space required, and the scope of expansion, is evaluated. Based on these, the decision to expansion can be taken. Non-extraction with interproximal reduction: In cases where expansion is not feasible, and extraction might disturb the profile of the patient, this option is recommended. Certain teeth are ground to reduce their width, and specific space is used to correct the alignment. To decide on the extraction or non-extraction protocols, there are other factors to be considered as well. The factors are age of the patient, the severity of crowding in the jaws, and face profile. Expansion is more successful in younger ages till growth is present. Growth completes by 16 years for females and 18 years for males. The severity of the crowding: Your case is not severe and can be managed without extraction (this is based only on the basis of attached occlusal photo). Face profile: Sometimes dental conditions can be managed with non-extraction, but the face profile demands extraction to improve it. Hence, this is an aspect, I cannot say now. In your son's case, there are two opinions: extraction and expansion. An orthodontist is a specialist who has had extra special training in the field of orthodontics, and I assume he must be right in his judgment to extract the teeth. The expansion could have been in his mind, but it might not deliver complete results, so he would have chose for extraction of the teeth. If you could share a few more details regarding your son and the treatment advised, I could help you with more precise options. Feel free to reach out for further queries and clarifications. Do rate the response and drop feedback to enable us to enhance the quality of answers. Have a nice day. Regards.

Hello,

Welcome back to icliniq.com.

There are two concepts going on in this case. All the details given to you in the previous response were according to the adult patients. Please do not apply those to your son's case. He is about 11 years old now and has lots of growth potential left in him.

As the permanent teeth develop, they elongate in the bone, and simultaneously primary (baby) teeth begin shortening.

These baby teeth guide the permanent teeth to where they should be erupting. And these permanent teeth send signals to baby teeth to start shortening. Both work in tandem with each other. At about 9.5 years of age, primary canines were advised to be extracted (as per the prescription attached). I am against extraction at this age. Primary teeth should not be extracted unless their natural time to shed off has been passed, or there is an absolute requirement to extract to create space for upcoming permanent teeth.

Dentition changes every moment at such growing age. So, it would be better to have fresh X-ray records taken before attempting expansion. Yes, one more growth spurt for your son is pending, which generally happens around 12 to 13 years of age and goes up to 16 to 18 years of age. We can utilize this time period to develop your child's jaws and avoid the extraction of permanent teeth. However, some primary teeth, if not shed, might have to be taken out intentionally.

A fresh set of records will give us a better idea of whether primary teeth should be extracted now or not based on the position and development of permanent teeth below.

Please share the X-ray (if taken) in the follow-up query for assessment.

Yes, generally, the teeth tend to expand the jaws naturally. So, it is better to hold the primary teeth longer until they naturally shed off or the permanent teeth are coming in a completely different position. Expanders are mainly used in the upper jaw. The upper jaw coordinates with the lower jaw and makes lower jaw expansion also happen as a reactionary result. Their lower jaw seems a little constricted but let us not forget his age. He still has some growth potential and a complete active growth spurt pending.

So, it would be better to assess the fresh records to know the current situation precisely before we decide on further planning.

Please ask the doctor for complete records to be taken, including all the photos you shared in the previous file. It had all the photos and X-rays required for the assessment of the case. A similar file at the current stage would be helpful for me to evaluate the case better.

Have a nice day.

Regards.

Hello,

Welcome back to icliniq.com.

I hope you and your family are doing well.

Based on the current records shared (attachment removed to protect the patient's identity), permanent teeth roots are forming well.

All the permanent teeth are present in the jaw bone. As per his age, things are going fine. You have to keep a check on the shaking (mobility) of his milk teeth which should start in about two months. This happens as permanent teeth come closer to the mouth and the roots of milk teeth reduce further. You can appreciate that in the current X-ray about the length of the root when you compare milk teeth and permanent teeth.

In my opinion, you do not require to get any expander treatment for your son. He does possess enough arch width, and it will be growing further in the coming years as he enters his growth spurt and his milk teeth are replaced by permanent teeth. He might require some amount of correction for crowding management. As of now, teeth are more in width than jaw width.

When milk teeth are replaced with permanent teeth, we get more space as milk teeth are wider than permanent teeth. They take up more space. So, some amount of space is expected from here. The jaw bone will also be growing along with him, while the teeth width will remain the same. So, some amount of space is expected here as well. But whether it will be sufficient to accommodate all the teeth is not sure currently.

As I had mentioned previously, you can go for a nonextraction approach here (in terms of permanent teeth), but we might have to extract milk teeth (if they do not shed off themselves), and permanent teeth are ready to come. Roots are forming fine for permanent teeth, and roots are reducing for milk teeth. So, we can observe for two to three months and check if milk teeth start shaking naturally. If this happens, there is no need for the extraction of milk teeth.

You can go for Damon's system of self-ligating braces for him. They have the tendency to improvise the jaw width and assist as it grows wider. They can be used, and we can avoid any procedures of IPR (interproximal reduction) or permanent teeth extraction in the future. However, this is a prediction, and we need to examine it frequently. Teeth positions change almost every time we see the patient. So, re-assessment will be required frequently.

I hope this clarifies some of your concerns regarding the treatment.

Feel free to ask for further clarifications or doubts.

Thank you.

Hello,

Welcome back to icliniq.com.

It is endearing to see that you have done your research on the treatment options for your son. The author meant that when the upper permanent canine forms and comes towards the mouth, it forms at an angle to the midline. If it is more tilted, the alpha angle increases, pointing more toward the midline, and when it is more straight, the angle is less. The milk teeth always guide permanent teeth to where they should be heading and where they will be coming out in the mouth. In cases of crowding, this phenomenon sometimes becomes inactive.

As the doctor (whom you sent the mail) mentions, we can go for a single tooth extraction on the right side as the tooth looks inclined. I am not sure if it has reached the point that we should go for deciduous canine extraction (milk tooth) as the X-ray is not very clear to carry out theoretical measurements. So when we extract, there is some space created in the bone. The crown of the tooth gets a direction to come down. It shall move away from the midline and straighten up. It moves away from the root of the lateral incisor. It gets a push to come down and not get stuck in the bone due to lack of space. And alternatively, when we do not extract, we wait for natural milk tooth root reduction.

The crown of the permanent canine is in close contact with the root of the lateral incisor. The teeth have only a certain eruption potential, which gets lost if space is not provided for them to come down, and it may get stuck in the bone (an impaction or impacted tooth).

The crown of the permanent canine may cause unwanted pressure to the root of the lateral incisor, resulting in temporary tilting of the lateral incisor and damage to its roots (called root resorption) which is subject to duration. If the impact is short enough, roots will not be damaged and will regenerate. If the impact duration is high, it could be irreversible damage. The situations are different in the lower arch. Even I do agree with the doctor's points. We can go for therapeutic extraction, But only for the right upper canine as the permanent canine is inclined (not sure, though, how much). Generally, canines come after the first premolar has erupted, which is not the case in your son, but we can move to single-tooth extraction. The root length seems fine, and it should not be a problem. We could wait it out also for a month or so, but later extraction would be mandatory if the permanent canine does not move from the current stage.

I hope I was able to resolve certain points and was able to explain the concepts.

Feel free to contact me for further details.

Thank you.

Hello,

Welcome back to icliniq.com.

Hope you are doing great and having a good time. Based on what we have discussed so far, the treatment options for your son are as follows:

1. Single tooth extraction from the upper arch to improve the permanent canine position. We will wait for a month to decide on the lower arch as the teeth seem well formed. Braces treatment will be done along with it.

2. As per the second author's recommendation, we can opt for expansion in the upper arch using an expander and avoid extraction. By expanding, we can create space, and the permanent canine can use this gained space, resulting in less crowding, and it might erupt without much hassle.

However, there are some concerns to consider. The coordination between the upper and lower arches is important. If we expand the upper arch, there is a possibility that the lower arch may also try to expand a bit, and we may end up with sufficient spaces in both arches. But if this does not happen, the upper arch will become wider than the lower one, and it will take some time to get back to coordinated arches. Crowding will likely occur when all permanent teeth come in, so braces treatment to de-crowd and align the teeth will be necessary.

Our goal is to ensure that no tooth is harmed in the future and that all teeth erupt properly. At 11 years old, your son is at a stage where canines and first premolars should be erupting soon. We can try removing any obstacles, such as primary teeth if they do not fall out naturally, or we can consider expansion to create more space. Your son will continue to grow, and there will be another growth spurt around 14-16 years of age, during which there will be definite jaw growth.

For the lower arch, the permanent teeth are coming in behind the primary canine. Although it is manageable, extracting the lower canines may make the guided path for the permanent canine a bit challenging. Alternatively, it might actually give some space for the permanent canine to adjust and come up. X-rays show that premolars are almost ready to come in, and when that happens, we will gain some space, which should be helpful for aligning the permanent canine. I agree with the second doctor's opinion of fixing a lingual arch to maintain the space. The lingual arch is a fixed wire placed on the backside of the lower arch, supported by permanent molars. It ensures that the space gained from premolars erupting will not be lost due to permanent molars shifting forward, allowing the canine to use the space. We can go ahead with the use of the lingual arch.

Regarding Damon braces, there are differing opinions in studies. Some claim that they assist in jaw growth, while others do not. Damon braces do upright the tooth and facilitate expansion, which can indirectly aid in jaw growth assistance. It is just an option, and we can also go with conventional braces. However, Damon braces could potentially help with assisted development. Using an expander at this age is possible, but we must exercise caution and not go for full-fledged expansion and then end up with constriction. Bone expansion can be done until around 15-16 years of age when the bone is not completely mineralized. After that, the use of expanders becomes limited.

I recommend discussing the pros and cons of all the treatment options again with the treating doctor and then making a decision. Both options are viable, and the choice will depend on what is best for your son's specific case.

Feel free to reach out for more information or clarifications.

Thank you.

Regards.

Hello,

Welcome back to icliniq.com.

Thank you for your warm response and feedback. Regarding the extraction of tooth #72, it is essential to clarify that tooth numbering systems differ worldwide. Some follow the FDI (federation dentaire internationale) system, while others use the Universal system. Based on #72, it should be the lower left deciduous lateral incisor (baby tooth), but from what I can see, it no longer exists in your son's mouth as it has already shedded off. Instead, #73 is visible, which is the deciduous canine. It is the small tooth present on the lower left side, to the left of the inside-placed tooth. If you correlate with the midline of his teeth, it will be the third tooth from the midline towards the left side.

At this age, a CBCT is not recommended. While it is not contraindicated, in my personal opinion, I would not prescribe it. Panoramic X-rays, along with smaller IOPA (intra-oral periapical) X-rays, should provide us with most of the necessary information. IOPAs are small X-rays that cover two to three teeth in one go. CBCTs require a specialized machine and are usually available only in diagnostic centers, radiology centers, or hospitals. Orthodontists generally do not have such machines in their offices.

Consulting an oral surgeon will not provide additional information as they mainly focus on extractions and not on planning teeth movement. If possible, you can visit a pediatric dentist (Pedodontist). Orthodontists are the experts who deal with impacted teeth management and teeth resorption. If no other options are available, then an oral surgeon intervenes to extract the impacted tooth. For impaction, the main criteria are to check if there is a clear path for the tooth to erupt and if sufficient space is present for its eruption. Regarding tooth resorption, it is crucial to examine the tip of the tooth root for any evident break in the continuity of the root structure or smoothness.

During his cleaning visits, please ask the doctor to take photos and share them here. Periodic assessment is necessary to observe how the teeth are moving and how spaces are being generated and utilized. Repeatedly advising panoramic X-rays should be avoided due to radiation effects. Limiting it to twice or thrice a year is advisable.

For further information, you can refer to the Ericson and Kurol article from the year 1988 in the journal "American Journal of Orthodontics and Dentofacial Orthopedics." They have conducted extensive research in the area of impacted canines. You can read their related articles for better information. There are no specific criteria for extracting or not extracting a primary canine. What we look out for is whether extractions would be beneficial or if they might cause harm. Factors such as the patient's age, the status of the permanent tooth developing underneath, and the situation of the arch (crowding, spacing, etc.) are considered when making decisions.

Always happy to hear from you and help you whenever possible.

Regards.

Hello,

Welcome back to icliniq.com.

Glad to know that the confusion is cleared up. I would be delighted to help you formulate the best treatment plan for your son.

Regarding your queries, yes, his permanent lateral incisors have erupted. These are the teeth next to the front two main central teeth. His permanent molars have also erupted and are coupled in occlusion with the opposing teeth (i.e., upper permanent molars are in contact with the lower permanent molars). Although they may erupt a bit more with age, both will be in a synchronized manner.

While it is true that permanent teeth are growing behind, we also need to consider the levels of the teeth, which are more important in the initial stages. Over time, both the location and levels become significant, and as the teeth almost reach a good level of eruption, we assess the locations. If we do not extract the deciduous teeth now, the permanent ones will get guidance to come closer to eruption, and the teeth that have already erupted behind can be aligned using braces. Braces will be required regardless of the approach, and it will not be too challenging to correct the alignment with braces. If we extract the deciduous teeth now, we clear the way for the permanent canines with minimal obstructions. However, there is uncertainty about how the permanent canine will align during the eruption. It may align by itself, but there are also chances that it might not get the correct eruption potential and guidance to erupt properly.

Regarding terminology and identification, I can only suggest you refer to internet images and search engines. Additionally, you can consult any oral anatomy books for better understanding. This is something taught in dentistry schools and takes a few months to grasp fully. I hope you understand that it is challenging to teach this with precision virtually.

You can post follow-up queries and I would surely like to help you with this.

Thank you.

Hello,

Welcome back to icliniq.com.

Based on the X-ray attached before two months, he currently has the following teeth:

Upper: Permanent central and lateral incisor, permanent first molar. Deciduous canine, first, and second molar. Under the gums: Permanent canine, first, and second premolars, second molar.

Lower: Same as uppers.

Expansion, if done, should be performed now for maximum effectiveness. One option to consider is expanding without extracting and preserving the deciduous teeth until they naturally fall off, except for the lower one. As we previously discussed, one lower deciduous tooth may be extracted. This approach allows us to create extra space while maintaining the deciduous tooth to provide some guidance to the permanent teeth. Based on the photos, I believe this approach can help us achieve all of our goals.

However, the attached study is not applicable to your son's case. Timing is crucial for selecting the appropriate expansion protocol. While your son has all the teeth required for the expansion, the strength or root status is not favorable. The study looks for teeth with stability and no resorption (i.e., no shortening of roots for deciduous teeth). Unfortunately, in your son's case, root shortening has already started. The study also suggests applying the expander to primary teeth, but his required primary teeth do not have the desired root status. Even if the mentioned expander is used, it will not be functional for long.

Therefore, I do not believe the study can be applied here. I recommend asking the orthodontist about their proposed expansion protocol and device, as well as which teeth will be used to fix the expander. They can provide more personalized guidance based on your son's specific situation.

Thank you.

Regards.

Hello,

Welcome back to icliniq.com.

The ideal age for using expanders, as per the article, is around seven years old. Since the X-rays were taken when he was about nine years old, that particular expander would have been doubtful in its effectiveness, not entirely but to some extent. The goal of expansion is to create space for teeth that have yet to erupt and then maintain that space to prevent complications. It should not cause any damage to permanent or primary teeth and should remain stable.

From an age perspective, early expansion is generally more favorable as the bone is not fully fused, and forces can help separate it with natural bone deposition on the gap created. Later on, expansion might not be as effective, as bone fusion is an ongoing process and varies from patient to patient. The possibility of extraction based on the current situation exists, but it cannot be precisely determined. It depends on his jaw growth, as previously mentioned. If there is sufficient growth, we may observe enough space to align all the teeth without extraction. Additionally, there are other methods apart from extraction and expansion to gain space, and expansion should rule out the need for premolar extraction, providing enough space to accommodate all the teeth in the arch.

Currently, he has permanent molars that can be used as anchor points for a part of the expander. The second anchor point we typically use is the first premolar, but he does not have those yet. Therefore, it would be best to wait until his first premolars erupt before considering something called rapid palatal expansion (RPE) or rapid maxillary expansion (RME). Once his first premolars erupt, we can use them as the second anchor point. In my opinion, the expansion anchor points are not available at the moment, but dental techniques are constantly evolving. It would be beneficial to hear what the doctor has in mind regarding expansion and their planned approach. It is always essential to learn more and continue evolving in dental treatment options.

Hope this helps.

Thank you.