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– A Dental Tragedy or the Standard of Care?

The concept and philosophy to extract healthy bicuspids is still being taught and practiced as a means to resolve the problems of dental crowding. The dental profession, including a growing number of orthodontist, are finally awakening to the fact that this technique has caused damage to many patients lives! This is bound to create controversy and considered heresy and false by a large body of orthodontist in today’s dental arena.

Females have been noted more commonly to be effected and compromised by this technique, due to greater joint laxity, the physiologic differences in joint and lesser muscle mass overall compared to men. The biologic basis for this claim is that patients with healthy bicuspids that have had them amputated from there mouths find themselves with a constricted dental arch form and often underdeveloped facial features which results in a compromised tongue position. The space that is reduced due to the removal of the bicuspids has now initiated a chain reaction of musculoskeletal compensations resulting in a forced forward head posture. This forward head posture than predisposes patients to a variety of musculoskeletal problems when aggravated, forcing the patient out of their physiologic adaptive range into pain and dysfunction that haunts their lives.

Some of the Problems
Some of the problems that have been noted are: jaw joints that are strained in a back position compressing the nerves and blood vessels behind the joints, teeth instability, continued airway/ breathing problems, muscular/ facial pain and headaches, shoulder and neck-aches and constricted arches resulting in sometimes leaving unclosed spaces between teeth. These are just a few of many problems that are observed by general dentist who routinely manage and care for these patients.

We Need to Wake-Up
Why remove healthy bicuspids if there is a better way to treat a crowded dentition and maintain proper physiology. We in the dental profession should finally realize after years of practicing and seeing the devastating results that these techniques have failed, coming up short of excellent dental health and an improved appearance. These outdated techniques lack physiologic reasoning and understanding to the health, function and well being of our patients.

“Standard of Care” or Malpractice?
Why does this technique continue? These techniques should not be considered the “Standard of Orthodontic Care”. If so, the standard certainly needs to be raised! Orthodontic textbooks and proponents state that the vast majority of crowded orthodontic cases involve an upper jaw (maxilla) that is too small or protruded, as opposed to a lower jaw (mandible) that is too large. If that is true, why do we make the already small upper arch smaller by extracting teeth? Logic and common sense tells us that it would be better to help the maxilla develop to its proper size than to shrink its size.

The proponents advocate using cervical headgear or appliances to move the molars back or extract the first bicuspids. They do not believe that arches should be developed, but rather lean towards extraction as a way of eliminating the crowding problem. This can lead to a constriction of the maxillary arch which subsequently prevents the mandible and jaw joints from assuming their correct forward position. This technique frequently impacts on the health of the TMJ negatively.

Each bicuspid has been know to be approximately 4-6 millimeters in width. If one removes two of these bicuspids from the dental arch, that arch will immediately be shy 8-12 millimeters in arch length. This is a significant amount of length when realizing how little it takes to develop a crowded dental arch that needs only 4-6 millimeters of arch length/ space to be regained in order to align all the teeth in a harmonious balanced manner.

It seems obvious that creating and developing space in the maxilla and the mandible both sagittally and transversely, by means of proper techniques is simpler and less damaging, allowing the mandible and jaw joints to come forward to their proper position. Extracting two bicuspid from each dental arch and trying to close the vacant spaces will naturally increase treatment time (trying to close spaces) and result in compromised physiology and facial development. The ill effects of the bicuspid extraction technique have been experienced too often by many!

Two prominent orthodontic clinicians and researchers, McNamara and Moyers, made the startling revelation that 80% of Class II malocclusions have retrognathic mandibles (mandibles in a back position). McNamara has further stated that less then 5% of Caucasian maxillas are truly prognathic (mandible in a more forward position). Sonographic Analysis and TMJ clincial exams routinely show disc displacement in class II patients with retrognathic mandibles prior to treatment and normal disc/ condyle relationship after functional/ neuromuscular treatment. In light of these facts, how can orthodontic practioners continue to apply techniques which cause retraction of the maxilla?

Misunderstanding of the human physiology, the musculoskeletal development, and a history of flawed research will only result in improper diagnosis and malpractice in dental care!

Alternative Techniques
Techniques to do this are readily available today and have been practiced in Europe since the early 1900’s. These non-invasive techniques have been growing in popularity throughout the United States for the past thirty years. Parents have been wising up to these serious life development decisions that will effect their child’s life and questioning the standard orthodontic treatments. No parent desires healthy permanent teeth to be removed from their child.

Keep It Simple
Why make something that is seemingly complex more complicated. Dentist who use these up to date techniques of working with the patient’s growth patterns to eliminate crowding and enhance the facial features dentally to their full potential may be found through the American Association for Functional Orthodontists or the International Association for Orthodontics. Please contact our office for more information. Thank you.

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