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Understanding Dental Malocclusions and Extractions
It is a common misconception that braces/ standard orthodontic treatment causes facial recession in most scenarios. however, in the vast majority of cases, braces or clear aligners do not negatively alter your facial profile. So... will braces recess you? Probably not.
This debate often comes down to two differing philosophies in modern orthodontics: Airway / Orthotropic Orthodontics and Camouflage Orthodontics.Traditional "Camouflage" Orthodontics:
What is camouflage orthodontics? Camouflage orthodontics aims to mask an underlying skeletal issue by simply moving the teeth to fit together, rather than correcting the actual position of the jaw bones. In specific scenarios, this approach CAN lead to unwanted changes in the facial profile.
Airway Orthodontics:
Airway orthodontics takes a different approach, focusing on preserving or improving jaw development, facial support, and airway health while achieving a functional bite. It emphasizes skeletal development and airway considerations in addition to dental alignment, with the goal of optimizing facial growth and oral function when appropriate.
Dental Malocclusions:
What are they? : A malocclusion is an improper alignment of the teeth or jaws that affects how the upper and lower teeth fit together. The type and severity of a malocclusion determine which orthodontic treatment is most appropriate. The classification system used today was developed in 1899. Known as Angle's Classification, it divides bites into three categories: Class I, Class II, and Class III. Although modern orthodontics has evolved significantly, this system remains the standard method for diagnosing bite relationships.
Class I Malocclusion:
What it is:
A Class I malocclusion is where the upper and lower jaws are in a generally normal skeletal relationship. The bite is considered “ideal” from a jaw position standpoint, but the teeth may still be crowded, spaced, rotated, or mildly misaligned.
Treatment approach:
Treatment usually focuses on aligning the teeth within an already balanced jaw relationship. This may include braces or clear aligners, sometimes combined with elastics for minor bite adjustments. In select cases with severe crowding or protrusion, limited extractions or enamel reduction (IPR) may be used to create space.
Orthognathic surgery for severe skeletal cases:
Rare in true Class I cases, but surgery may be considered if there are significant skeletal asymmetries or vertical discrepancies that cannot be corrected with orthodontics alone.
Class II Malocclusion:
What it is:
A Class II malocclusion occurs when the upper jaw and teeth are positioned ahead of the lower jaw, or when the lower jaw is underdeveloped. This can result in a deep overbite, increased overjet, and reduced chin projection.
Camouflage approach:
One common approach is dental camouflage, where the upper premolars may be extracted in some cases to create space, followed by retraction of the front teeth using braces and elastics. This aligns the bite but does not change the underlying jaw position. In certain facial types, this can reduce lip support and make the profile appear flatter.
Correct approach: Functional appliances, such as the Herbst appliance or Twin Block, which posture the mandible forward to encourage more favorable jaw development during growth.
- Headgear in some cases, used to restrict forward maxillary growth or distalize upper molars.
- Palatal expansion, when arch constriction is present, to improve transverse width and create space without extractions.
- Temporary anchorage devices (TADs) in selected adolescent or adult cases to assist controlled tooth movement without excessive dental compensation.
In severe skeletal Class II cases, especially in adults, orthodontics alone may not be sufficient. Surgical options include:
- Bilateral sagittal split osteotomy (BSSO) to advance the mandible
- Le Fort I osteotomy if maxillary position also contributes
- Bimaxillary (double jaw) surgery in combined discrepancies
Class III Malocclusion:
This is unfortunately the most brutal of the three...
What it is:
A Class III malocclusion occurs when the lower jaw is positioned ahead of the upper jaw, or when the upper jaw is underdeveloped. This can result in an underbite, concave facial profile, and anterior crossbite.
This could be caused by a multitude of things:
A condition called prognathism, commonly found in African Americans which is a structural facial abnormality where the lower/upper and or both protrude outward.
The upper maxilla being retruded, often caused by genetics (found in mainly people of east asian and hispanic descent)
or due to environmental factors such as cronic mouth breathing, bruxism, etc.
Camouflage approach: Orthodontics usually cant fix this skeletal issue unless they extract lower teeth and recess your mandible. This results in a collapsed lower lip and severe chin recession, leaving the patient with both jaws recessed. Sometimes mild cases may be treated by compensating with tooth movement, such as advancing upper incisors and retracting lower incisors using braces or aligners. However, this approach has limits and may not fully correct facial imbalance in skeletal cases.
Correct approach:
- Facemask therapy (reverse pull headgear) combined with rapid palatal expansion (RPE) to protract the maxilla forward and improve midface projection.
- Expansion based protocols, when the upper jaw is narrow or underdeveloped, to improve arch width and assist orthopedic correction.
- Early intervention to influence growth direction before skeletal maturity.
For moderate to severe skeletal Class III cases, surgical correction is often required. Common procedures include:
- Le Fort I osteotomy to advance the maxilla
- Bimaxillary (double jaw) surgery for combined jaw discrepancies
Surgery addresses the underlying skeletal relationship, allowing the teeth to be aligned in a stable and balanced position afterward.
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The Problem with Extractions and Retraction:
The primary scenario where orthodontic treatment can cause facial recession is when healthy premolars are extracted followed by heavy retraction to fix crowding or a protrusion.When these premolars are removed and the lateral incisors are pulled back, the dental arch is both narrowed and shortened, which flattens the lips, diminishes facial support, and visually "recesses" the profile.
Furthermore, retracting these anterior teeth drastically reduces the overall volume of the oral cavity; (bone and cartilage in the mouth) which actively regresses the maxilla and collapses subnasal support. this leaves less room for the tongue, forcing it backward into the pharynx and potentially compromising the airway which increases the risk of sleep apnea.
Traditional orthodontists often use this method to treat crowding because it is a fast, easy, and profitable shortcut to straight teeth, rather than doing the harder work of expanding the jaw. However, many advanced, airway focused orthodontists now treat extraction and retraction as a last resort, opting instead for jaw expansion to safely create space without collapsing the facial structure.
When Extractions Are Appropriate:
While premolar extractions are often debated online, with "buzzwords" they remain a legitimate and widely used orthodontic tool when applied for specific indications rather than as a default solution.Extractions may be appropriate in cases such as:
- Severe crowding, where there is insufficient arch space even after expansion or mild enamel reduction
- Significant dental protrusion, where reducing incisor prominence is needed to achieve proper lip support and bite function
- Dental asymmetry or midline discrepancies, where removing a single tooth can help correct alignment differences between the left and right sides
- Periodontal or dental limitations, where moving teeth too far outside the bone envelope could increase risk to gum and bone health
- Compensatory treatment in skeletal cases, when surgery is not indicated or not chosen by the patient
My Case:
In my own case, treatment involved a combination of palatal expansion followed by a single unilateral premolar extraction to address a significant midline discrepancy and asymmetry. Expansion was used first to improve lateral width and create additional space within the arch. However, because the asymmetry was not purely due to crowding but also genetic involved a shifted dental midline, expansion alone could not fully correct the imbalance. In a scenario like mine, getting a single premolar extraction on one side is a necessary tool; removing just that one tooth allowed the orthodontist to shift the teeth over and correct my severe midline discrepancy without constricting the entire arch or causing the total facial recession seen in lazy, traditional protocols.Other Common Misconceptions and Topics:
Elastics:
Another misconception is that wearing orthodontic elastics inherently causes recession. Elastics themselves are just tools; the damage comes entirely from HOW they are used to camouflage different malocclusions. The reality is, elastics themselves cannot generate enough force to inherently alter the facial structure of your face. This can only happen if you genuinely wear them for 20 years straight.
Orthodontic elastics are small rubber bands used to apply controlled forces between the upper and lower teeth. They are not a standalone treatment—they are a tool used within a broader orthodontic plan.
Class II elastics:
Commonly used to help correct Class II relationships by pulling the lower jaw forward and/or retracting upper teeth. In dental camouflage cases, they may contribute to dental compensation rather than skeletal correction.
Class III elastics:
Used to assist in correcting Class III relationships by pulling the upper teeth forward and the lower teeth backward. In skeletal cases, they primarily mask the discrepancy rather than change jaw position.
Palatal Expansion:
Palatal expansion is an orthodontic treatment used to widen the maxilla when it is too narrow relative to the lower jaw. This narrowness can contribute to crowding, crossbites, and functional shifting of the bite.Types of expansion:
- Rapid Palatal Expansion (RPE):
Common in children and early teens. Uses a fixed device to gradually separate the midpalatal suture, allowing the upper jaw to widen more skeletally than dentally. - MARPE (Miniscrew Assisted Rapid Palatal Expansion):
Used in adolescents and some adults. Combines expansion screws with mini-implants to achieve more skeletal expansion with less dental tipping. - SARPE (Surgically Assisted Rapid Palatal Expansion):
Used in adults where the suture is fused. Expansion is performed with surgical assistance to allow skeletal widening.
- Increases upper arch width
- Creates space for alignment without extractions in some cases
- Corrects posterior crossbites
- Can improve smile width and dental coordination between arches
Expansion primarily affects transverse width. It does not directly correct forward/backward jaw position (Class II or Class III), although it may support other treatments.
Other Common Malocclusions Worth Mentioning:
- Posterior crossbite: back teeth are too narrow on the upper arch
- Anterior crossbite: front teeth are reversed (often seen in Class III tendencies)
- Unilateral crossbite: occurs on one side only, sometimes causing jaw shifting during closure
- Open Bite: A vertical gap between upper and lower teeth when biting down. Can be dental or skeletal in origin and may be associated with tongue posture or vertical growth patterns.
The ultimate takeaway is that orthodontic treatment is not inherently good or bad for facial structure. It is a system of biomechanics, and outcomes depend on how those forces are applied to each individual case.
There is no single correct philosophy that applies to everyone. Camouflage, expansion, functional appliances, and surgical approaches all have valid roles depending on age, anatomy, and severity of the malocclusion. The most appropriate treatment is the one that achieves a stable bite while respecting the limits of the patients facial structure
Ultimately, modern orthodontics is not about choosing between straight teeth and facial aesthetics, but about balancing both within the constraints of biology.
Sources:
Contemporary Orthodontics
Contemporary Orthodontics
**Selected for Doody’s Core Titles® 2024 with "Essential Purchase" designation in Dentistry**The leading text for orthodontic education! With a world-www.elsevier.com
- Orthodontics: Current Principles and Techniques
Contemporary Orthodontics
**Selected for Doody’s Core Titles® 2024 with "Essential Purchase" designation in Dentistry**The leading text for orthodontic education! With a world-- Edward Angle (Angle Classification of Malocclusion, 1899)
https://pubmed.ncbi.nlm.nih.gov/37276298/- American Association of Orthodontists
https://www.aaoinfo.org/- American Dental Association
https://www.ada.org/- William Proffit (Orthodontic diagnosis & treatment planning concepts)
https://www.ncbi.nlm.nih.gov/nlmcatalog/101578397/- Henry Fields
https://www.aaoinfo.org/
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