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November 11, 1998

Orthodontic Controversies

CITATION: Controversies in orthodontics Dent Clin North Am 1990 Jan;34(1):91-102 Bramante MA, Graduate School of Orthodontics, Columbia University School of Dentistry, New York, New York.

Three controversial interrelated aspects of orthodontics have been reviewed: retention, the effect of third molars on lower anterior crowding, and extraction and nonextraction orthodontic treatment. Recent studies have shown that unacceptable lower anterior crowding occurs in 90 per cent of well-treated extraction cases. The implication is that nonextraction cases should be 90 per cent or higher. In view of our present general inability to identify the 10 per cent that will remain acceptable, some form of indefinite retention is advised. A literature review of the effect of third molars on lower anterior crowding finds strong opinions on both sides of the issue. Similar studies often show dissimilar conclusions, particularly when observing cases of third molar extraction or agenesis. Certainly the problem is multifactorial; however, the vast bulk of the evidence indicates that the third molars play an insignificant role in lower anterior crowding. Extraction of teeth for orthodontic treatment prior to 1900 was prevalent and indiscriminate. From the turn of the century to the mid-thirties Angle moved the specialty away from extractions to a relatively rigid nonextraction treatment philosophy. Dissatisified with relapsing Class II cases, recurrence and aggravation of crowding, and what he felt were bimaxillary full faces, Tweed and others, circa 1935, redirected the profession back to extractions with a more disciplined approach to treatment by the removal of four first premolars. Fifty years later we have found that extraction treatment and uprighting lower incisors does not prevent long-term postretention crowding and that flattened profiles are not always esthetically desirable. Earlier treatment of maxillomandibular basal discrepancies by old and new treatment philosophies and mechanics have produced more stable nonextraction corrections. Better control of leeway space and a reduction in caries has helped reduce the amount of lower anterior flaring that was seen in the nonextraction cases in the first third of the century. These reasons have moved the specialty of orthodontics to a mixed but more nonextraction-oriented approach to treatment.

DISCUSSION: There have been a number of highly contested philosophical approaches to moving teeth the past few decades. Fortunately for patients, orthodontic treatment modalities are shifting more and more away from "traditional orthodontics" and toward Functional Jaw Orthopedics....a progressive form of orthodontics and orthopedics with the similar emphasis on straight teeth, but more emphasis on balanced JAWS and the orthopedic effects of treatment and treatment goals. Why is this important? Because the Jaws surround the gateway to the human cardiopulmonary system, the upper airway.

What does this all mean to you?

  1. Teeth need active retention indefinately, after any form of braces.
  2. Extraction of bicuspid teeth for orthodontic reasons is becoming less needed and/or less desirable--("flattened profiles").
  3. Extraction of 3rd molars to prevent orthodontic relapse is not warranted.
  4. Early treatment is better.
  5. Orofacial airway scientific exploration is minimal to date, but should grow dramatically as its impact becomes more recognized.

FUTURE: Even as "traditional orthodontics" moves towards Functional Jaw Orthopedic modalities, a new medical frontier is unfolding. And that frontier starts as early as birth in evaluating the structural surroundings of the gateway to the airway.

Take Care,
Dr. David Page


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