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Case Study: Severe Overcrowding

Orthodontist Yorba Linda
Orthoyl January 30, 2024

When adolescent patients are brought to the orthodontist to treat crooked teeth, they or their parents can come in with preconceptions about what to expect from treatment, as well as steps they think should be avoided at all costs. One strongly held idea is that having permanent teeth extracted as part of orthodontic treatment is always bad, resulting in a smile that looks less full or is even retroclined (with teeth tilted back toward the roof of the mouth). The assumption that goes along with this is that if the upper arch is treated with a palate expander, there is never a need to extract teeth.

A recent case we had in our office illustrates that, in fact, extraction may be a necessary part of achieving a healthy bite and attractive smile. While we prefer to preserve all healthy permanent teeth, it isn’t always possible in cases of severe overcrowding. For this patient, her ideal results came from both expansion and extraction as part of comprehensive treatment.

Treating Crowded Teeth

When this patient came to B Orthodontics, she was 12 years, 11 months old. Her teeth were severely crowded and she had a narrow upper jaw, restricting the space available for her teeth. Her treatment included an upper rapid palatal expander, extraction of the first premolars, and braces to straighten and align the rest of her teeth, a process that took 24 months.

Rapid palatal expanders (RPEs) are often used during Phase 1 treatment, which is conducted when patients are younger—obviously not possible in this patient’s case, since we first saw her after she was past the point of early treatment. However, an RPE can have benefits as part of comprehensive treatment as well. The difference is that with younger patients, who are treated before the bones of the palate have begun to fuse, an RPE achieves stable skeletal expansion that creates actual new room in the arch.

With older children, the palatal expander may still accomplish some bone expansion if the palate has not fused completely. This occurs around puberty, so it is different for each child, and it’s impossible to pinpoint exactly when the connective tissue finally turns to fused bone. At this age, however, the result is more tooth tipping, movement that corrects the angle of the crown of the tooth, which helped to broaden and reshape this patient’s upper arch.

From the outset, it was evident that the RPE alone would not create the room necessary to perfectly align this patient’s teeth. However, our goal is always to proceed as conservatively as possible and apply the minimum necessary treatment for ideal results, so the expansion was done first. Then we reassessed the need for extraction after the expansion was completed.

The premolars, which are located between the canine teeth and the molars, are the most common teeth selected when extractions are needed to create space to address crowding issues. After the first premolars were extracted, braces were used to straighten our patient’s teeth, using the space gained to pull the remaining teeth into smooth alignment.

Should most patients expect to have extractions as part of their orthodontic treatment? No. In fact, they’re relatively unusual—but when they’re necessary, it may be impossible to obtain satisfactory results without them. In our patient’s case, what we were able to accomplish with a combined approach of expansion and extractions gave her a beautiful smile she can now share with confidence.

Individualized Orthodontic Care

At B Orthodontics, we’re dedicated to helping our patients with individualized treatment options chosen to meet their treatment goals and lifestyle. Whether orthodontics are started in early childhood, adolescence, or adulthood, we’ll work with you to devise the right course of treatment to give you the lifelong healthy smile you deserve. With flexible payment plans and strategies for maximizing your insurance coverage, our office keeps treatment affordable and accessible. To get started, contact us here for your free initial consultation.

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