Extractions vs. Non-Extractions

A question that comes up often in orthodontic consultation, diagnosis, and treatment planning is: Will it be necessary to remove premolar teeth to straighten your teeth or to correct your malocclusion (bite)?

The answer is that it depends.   There are several factors to consider, including the degree of crowding; flaring; thick versus thin gum tissue; missing, fractured, diseased, or impacted teeth; and the severity of the overbite or jaw imbalance.

A general observation is that about 25 percent of the time extractions are clearly not indicated. These are situations where crowding is mild to moderate, the front teeth are not flared forward, and bite and jaw discrepancies are mild to moderate.

10-25 per cent of the time (percentage varies according to the local prevalent genetic make-up) extractions are definitely indicated.   These are situations where the orthodontic patient has either extreme crowding, flaring of teeth, or a significant overbite.

The 50 to 65 percent of patients in the middle of the spectrum are considered to be border line and usually started on a non extraction trial.    These days, most folks in this group complete their treatment without removing teeth.

The good news is that, looking at all patients combined, premolar extractions can be avoided about 70 to 90 percent of the time!

Here at Kineret Orthodontics, most extraction cases are started non-extraction.   The rationale being that once premolars are removed, you can’t put them back.  So if there is a small but reasonable chance of substantial response to wires and rubber bands, it is best to defer extraction decisions until mid-treatment.

Even when it is certain at the outset of treatment that extractions are indicated, I prefer to defer extractions until mid-course.  The reason being that by mid-treatment we are in large arch wires, have started rubber bands and can more strategically and efficiently close extraction sites.

Four Keys to Making a Good Orthodontic Decision - By Dr. Stephen Kineret

First of all, choose the right doctor

In this state, it is legal for general dentists to offer and provide orthodontic treatment to their patients (irrespective of the intensity of their orthodontic education).  So, in my opinion, you should be clear on the differences between the levels of training, experience, and expertise that exist between a general dentist with a special interest in orthodontics and a university trained board eligible or certified orthodontic specialist.  Short answer:   the orthodontic specialist made the commitment of a full time 2 or 3 year postgraduate residency in our specialty, earned a clinical certificate (and a masters degree -credentials:  DDS, MS if they did a research project and thesis).

In comparison, the level of training for a general dentist with a special interest in orthodontics is based on the minimal dental school curriculum exposure to basic orthodontics and the weekend courses they have attended.

The orthodontic specialist has limited his practice to orthodontics alone, whereas the general dentist also provides other services.  In my mind, the compounding of limited specialty practice with a 2 or 3 year post graduate residency experience distills down to a substantial difference in levels of experience and expertise.

Here is another way to look at this.  If you needed a quadruple bypass, who would you choose to do it—an experienced, well-trained cardiac surgeon or the family doctor?

Secondly, follow these guidelines:  

Do not base your decision on price but on value. 

I believe the general erroneous assumption made by the public is that most doctors’ training, philosophy and results should be the same because our profession is regulated by the state.   Remember appearances sometimes can deceive.  And guess what?  In our community, fees don’t deviate all that much!  So the question is:  Do you want to be in a great practice and have a very positive experience for you or your child or do you want to save a few dollars a month?   May I suggest a checklist to help you choose?

If the conditions on the following checklist have been met, congratulations; odds are that you have made a great investment in your oral health.  You have found your new orthodontic home.

Checklist

You have been referred by another patient(s) who had a very positive experience in that office

The doctor can show you similar cases with pleasing results (there are before and after examples on our blog and website)

You feel that there is very good communication and direct and frequent interaction with the doctor

The staff is very friendly and caring

The office is conveniently located and offers office hours throughout the week and runs on time

The office implements contemporary technologies and infection controls

The office helps you maximize your insurance benefits and offers flexible no interest and no down payment options, and cash discounts

Choose the right office based on the above checklist/criteria-do not get bogged down in terminology or types of appliances used.

There are fads in orthodontics, just like in other professions and industries.  Decisions should be based on good diagnosis and treatment planning not on marketing fads, or using the latest, greatest widget.  I frequently see this kind of thing happen when the general dentist gives the patient/parent several referral cards; the patient dutifully gathers multiple diverse opinions and then becomes very confused.  Instead, use my checklist.  It will help, I promise.

Make sure your child is on board and encourage them to cooperate and follow directions to maximize results

I always tell my patients that a great patient and an average orthodontist can often get better results than the reverse.  Meaning, this is all about team work folks!  If you really want to get a great return on your investment, keep your kids on task with doing their part in treatment—compliance is paramount!  Treatment always turns out better and usually moves along faster, if patients keep their appointments, keep the teeth, gums and braces clean, wear their rubber bands consistently, and are careful not to loosen the non-permanent adhesive that attaches the braces to the teeth.

In our office we have many incentives and rewards in place to encourage compliance and responsibility.  However, if you can maintain tandem reward systems at home, the gains are more than doubled!   The side benefit of this is the maturation and personal growth that occurs when patients take responsibility and become active participants in their treatment.

By Dr. Stephen Kineret