For many years, orthodontists have recommended extracting pre-molars (bicuspids) to make room in the mouth for crowded teeth. This is a standard, accepted practice in the specialized dental field of orthodontics. Millions of patients have been treated this way and now have beautiful, straight teeth. Having straight teeth is certainly a worthwhile goal, but do these extractions have consequences worth considering? And can a crowded mouth be treated without extractions?

Let's think about the tongue for a moment. It's very strong and made of lots of muscle. It has a given size and must fit inside the mouth. If it sits too far back in the mouth, it blocks the airway, which can cause sleep apnea. If it sits too far forward, it can create a space between the upper and lower teeth, which can lead to TMD/TMJ. If there isn't enough room in the mouth for the tongue, the tongue will sometimes make space for itself. By pushing out against the teeth like an orthodontic appliance, the tongue moves the teeth until it has enough room, and this can cause gaps between the teeth.

What kinds of situations exist where there is inadequate space in the mouth for the tongue? Overbites are one common situation. An overbite is where the lower front teeth are less visible than they should be. The bite is over closed and this reduces the volume inside the mouth. People with overbites frequently have spaces between their teeth because their tongue demands extra room. Bicuspid extractions for orthodontics are another situation that reduces the space inside the mouth for the tongue. After removing the bicuspids, the teeth are usually moved orthodontically to constrict the arch of teeth, eliminating crowding and gaps. When the dental arch is constricted, the tongue has less room.

What are the alternatives to having bicuspid extractions in conjunction with orthodontics? If the problem is crowded teeth, expansion of the arch is an excellent alternative. This can be accomplished with an appliance that gradually expands the palate. Sometimes a minor surgical procedure must be done to allow the palate to separate. Arch expansion provides sufficient room for the teeth and for the tongue. There is also another advantage that is more technical from a dental standpoint. When the arch is constricted, the teeth are often tipped inward. This causes the wrong parts of the tooth to bite, which can lead to excessive wear, bite problems, TMD, and an unaesthetic look.

What if the problem is an overbite? In the case of an overbite, the first obstacle to overcome is to find the proper relationship of the upper jaw to the lower jaw-without regard to the teeth. In other words, imagine a denture patient with no teeth. The dentist must still find the proper position of the upper jaw with respect to the lower jaw. When the patient has an overbite, dentists use TENS therapy to relax the jaw muscles in order to find the ideal jaw position. The ideal position is recorded precisely, then, an orthotic is made to act as an ideal facsimile of the lower teeth in proper jaw relationship to the upper teeth. Once this position is established and stabilized with an orthotic, orthodontic techniques can be used to permanently move the teeth into this jaw relationship. The overbite is eliminated, the tongue has more room, and the face is more balanced. Oftentimes, patients with overbites have a collapsed appearance of the lower third of their face. This type of orthodontic treatment to correct an overbite is like a non-surgical facelift.

Sometimes, extractions are necessary to get the best possible result. It is always best to find out what alternatives exist.