Dr. Greg Jorgensen
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Rio Rancho, NM 87124

The Jorgensen Orthodontics Blog

Can Orthodontic Expanders Be Used on the Lower Teeth to Avoid Extractions?

Posted by Dr. Jorgensen on April 13th, 2013

I don’t think I’ve ever had a patient excited about having teeth removed as part of orthodontic treatment. Nevertheless, there are some mouths that just don’t have enough room for all 32 teeth (in fact, if you count wisdom teeth, less than 15% of Americans keep all their teeth). Parents seem relieved when I offer the option of an expander in the upper arch as an alternative to extractions. Can expanders also be used in the lower arch?

The anatomic feature in the upper arch that allows for the use of palatal expanders is the mid-palatal suture. In children younger than about 15 years of age, this suture or growth plate is immature and “stretchable.” If soft cartilage is present in the palate, the two halves can be slowly separated by a series of very small “activations” of an expansion screw built into the expander. In still-growing patients a gap develops between the upper two front teeth as evidence that the suture has been opened rather than the crowns of the teeth being merely tipped outward. If the mid-palatal suture has already fused however, there is no separation of the front teeth and any expansion obtained is purely dental (just tipping the teeth towards the cheeks).

The problem with using an expander in the lower arch is that there is no suture close to the teeth to expand. There are two growth plates in the lower jaw, but they are located up by the joints, not down by the teeth. Any expansion that takes place in the lower is strictly tooth movement. There is no problem with this as long as there is sufficient bone and gum around the roots. Terms commonly used to describe expansion in the lower arch are “uprighting” if the teeth are tipped inward initially and “flaring” if they are already upright and get pushed over the edge of the supporting bone by the treatment.

There are lots of ways to upright or flare the teeth in the lower arch to resolve crowding. Some orthodontists use “sagittal” appliances (removable retainers with an expansion screw built in) while others use lip bumpers. Some doctors use a wire behind the teeth with a spring on it. I have even seen banded expanders with jackscrews just like those we use in the upper. What the research shows however is that any expansion that takes place in the lower arch is accomplished by tipping teeth only and not by moving bone.

Understanding that the results will be the same no matter how obtained, I feel that the most efficient way to tip the teeth AND align them at the same time is with fixed appliances (braces). The expansive force comes from the wires themselves and springs that we thread over them to push the teeth apart. The bottom line is that resolving crowding in the lower arch requires either tipping the teeth or extractions. The decision to expand or extract is determined by the supporting structures (bone and gums). The shape and size of these structures are genetically determined and it is the orthodontist’s job to decide which option will produce a final result that is attractive, healthy, and stable.

Today’s 3D imaging makes this decision more objective than ever. A cone beam scan clearly reveals the thickness and height of the bone overlying the roots of the teeth. Digital models created as part of the Suresmile protocol using this 3D data not only show me the current condition of the bone, but the software also allows me to simulate the results that would be obtained by each treatment option. I have actually changed treatment plans on several patients after performing virtual treatment using Suresmile. I have identified several patients that needed teeth removed to keep their roots in bone. I also changed a surgery case to a non-surgery case after simulating the treatment outcome. That is revolutionary!

Can the lower arch be expanded? Absolutely. Can expansion be used in every case to eliminate the need to have teeth removed? Nope. Ask your orthodontist if you have enough bone to allow for the flaring that will take place if teeth are not removed. If you are not a candidate for expansion, realize that the removal of teeth may be necessary for the best outcome.

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa in the United States. Dr. Jorgensen’s 25 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor can he select treatment plans for readers. Because he has over 25,000 readers each month, it is impossible for him respond to all questions. Please read all of the comments associated with each article as most of the questions he receives each week have been asked and answered previously. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.

69 comments so far in response to “Can Orthodontic Expanders Be Used on the Lower Teeth to Avoid Extractions?”

  1. Rebecca says:

    Hi. I am 42 years old and have been wearing braces for over 2 years. The Orthodontist that I am seeing wants my lower arch to be expanded to improve my bite. Even with braces I still have an overbite on my upper teeth. To try and expand my lower arch the Orthodontist gave a removable appliance to wear.

    I recently was traveling and had to see another Orthodontist for a check up and changing my elastics. She told me that an appliance in someone my age usually does not work and that it could push my teeth out of my bone. She said that she would use wires to expand my lower bite.

    The Orthodontist that wants me to wear the appliance says that if it does not expand my bite then I will need surgery.

    My main question is…Should I wear this removable appliance? Or should I seek out another Orthodontist who has a different treatment options?

    Thank you!

    • I can’t make that decision or you. I will say this, a removable appliance will not expand the lower jaw. It will only tip the crowns of those teeth outward. As for the teeth being pushed out of the bone, it depends upon how much bone you have and how much expansion you receive. I’m personally not a fan of lower expansion appliances.

      • Dr Jorgensen says:

        Dear Dr Jorgensen,
        I am 45 yrs old (fem.). My problem is the upper molars only make contact on the outer extreme edge of the lower molars. I have just started treatment with traditional braces and the plan is to expand the lower arch and move the teeth by using criss cross elastics from the inner lower tooth to the outer upper molar. I estimate my teeth should be moved at least 2,5 mm each side.
        My question is this realistic and which danger signs should I be cognisant of?
        In the plan I agreed to a necessity of surgical intervention but so far the surgeons I have seen have advised me against surgery.
        Virginia Heine

        • The risks of correcting SKELETAL crossbites with DENTAL movements is that you may move the teeth out of the jaw bone. Your orthodontist should constantly be monitoring the outside surfaces of the roots to make sure that recession is not occurring.

  2. Shannon Ford says:

    My daughter 12 is supposed to get a retainer with a built in expander for her upper jaw and a schwartz appliance for the lower. She has only lost 6 baby teeth and has crowding on top and bottom. Her orthodontist used 3D imaging. He said she is borderline for having enough gum/bones to use the lower appliance. He mentioned her facial growth pattern is longer and this is why he wants to use the schwartz versus the braces. He said this may not prevent having to pull permanent teeth. This phase is supposed to last 17-20 months. What reasons would a schwartz be better than braces, or in your opinion are the lowers a waste of time and money? Thanks!

    • I doubt that you are seeing a real orthodontist. Orthodontists don’t use Schwartz appliances much any more. A lot of dentist who are trying to do orthodontist use them. I would ask if he is a real specialist and then see someone else if he has mislead you.

      • Shannon Ford says:

        Hello, thank you for replying. He is an Orthodontist. Would braces then do the same thing as the Schwartz? I saw another Orthodontist before this one, and he wanted to go with the standard upper expander. When I asked about crowding in the lower jaw, he said in his experience the lower jaw will also expand a bit. Is that true? I’m just wondering whether to go with him instead. Thank you for your help.

        • I can do the same with braces in the lower as he can do with a Schwartz. You CAN expand the lower by tipping the teeth outward, but there is no growth plate in the lower jaw that allows the width of the bone to change. I honestly doubt your doctor is a specialist and doesn’t know these basic things.

  3. Aileen says:

    According to my dentist I have tmd so he let me wear splinter for two weeks then now 4 months wearing expander upper and lower. But sometimes I remove it and don’t like to wear for weeks . I noticed my face is not equally shape and my lips are not in proper shape or let me say not in proportion..please forgive me in my English . My upper teeth are much wider now than the lower teeth. The problem with my teeth I have missed tooth so there’s space while wearing braces and expander at same time.have to adjust once a week. I observed also some of my teeth on the side when I bite hits the brackets. That’s why sometimes my brackets replaced. I want to ask for another opinion cos I am not happy with his work . It’s so expensive and sometimes he let her assistant do the adjustment and changing rubbers and installing the bracket.

    • I cannot diagnose or treatment plan your case remotely, but I will say this: 1) It is normal for expanders to change your bite, but not normal for them to change the shape of your face or lips, 2) brackets may come off if you are biting on them because your bite is off, and 3) if you are not happy with the work being done, please get a local second opinion. Good luck!

  4. Nikko says:

    Hi! Ive been really depressed these past few weeks because of the drastic change that has happened to my face. Okay so here’s what happened. Ive got a dental filling on my upper right second bicuspid last year. The filling turned out to be high that my left set of molars wont touch anymore without me forcing it. I didn’t get the chance to have it fixed coz the dental clinic is far from my place. Well, I planned to have it fix but after two weeks. I got used to my “new” bite so I decided not to visit the dentist anymore, thinking the high filling wont be a problem.

    BUTTTTT! It caused my lower jaw to recede inwards. My mandibular angles are not visible anymore. After the first five months of getting the filling, it was only the left jaw that did recede, but I ignored it coz its not really obvious and I kinda like having a crooked smile. I didnt know then that my right jaw will move inwards as well. Unfortunately just two weeks ago I noticed the same thing happened to my left jaw already. Both of them are now receded inwards, and my face looks narrower than ever. My lower teeth and upper teeth are now pointing inwards. Like when I took a picture of myself in a profile view, you cant see my mandibles anymore, just a saggy skin from my ears to my neck.

    AND ANOTHER THING, Ive also got a terrible overbite. And I dont really feel comfortable with it, asside from my face looking shorter, Im having moments when its just hard for me to breath. So I had to release my bite and open my mouth. I feel more comfortable when Im not biting my teeth together. I actually feel more comfortable and normal when I move my lower jaw forward, coz that is how they are positioned before.

    My concern is, if I get my lower and upper teeth tilted outwards again like how they used to be, will this bring back my jaw to their old shape?

    I’m really frustrated. Even my friends did noticed the change in my appearance. Ive been receiving comments from them saying I dont look good anymore.

    I’m 22 years old by the way. And I dont wanna live the next years of my life looking like this.

    • I’m sorry to hear that you’re having some issues Nikko. I have not examined you and can’t speak to your situation specifically, but I can say this. I cannot imagine how a dental filling can cause all of this change. Dental fillings, even high ones, cannot cause the facial and jaw changes you are describing. I think you should be examined by an oral surgeon who specializes in jaw structure. You may have something else going on (like degenerative arthritis). Dental fillings do not make your jaw size and position change.

  5. Helen says:

    Please provide your professional opinion. I am 44 years old, had braces in my 20’s, 4 teeth were pulled if I remembered, were not compliant in wearing retainers, fast forward to now, terrible bite, only 2 teeth in the entire jaw touches. Many fillings on the side/up/bottom/molars are cracking and in need of replacement. When I went for an ortho consult 4 years ago, the xray showed right condyle is thinned out. I grind/clench a lot at night.

    Since I am faced with potentially more root canals, new crowns every 5 years, old fillings not working; gum lines receding; exposing roots. Many traditional orthos would not treat me because of my thinned condyle. I am faced with catch 22 situation — if I don’t get ortho, potential crowns,fillings, root canals — will fail. If I get ortho, it may exacerbate my non-existent TMJ symptoms. I am not in any pain; except I have assymetry of my face; right cheek/side of face is bulkier than the left.

    However,functional ortho’s who uses removable expanders have shown me prior patient’s x-rays and how their treatment can work. Would you recommend me going towards this route? Expanders on the lower jaw for a few months, then traditional braces.

    I am afraid of tempering pandora’s box — asymtomatic with TMJ but yet deal with such a horrible bite, mouthguard ineffective to protect my teeth from breaking.

    What should I do please?

    • Unfortunately I cannot diagnose or treatment plan individual patients on an Internet blog. I will say this generally, I never use expanders or “functional appliances” in adults without surgery. All you’re going to get is tipping of the teeth (especially with removable expanders). I would recommend that you get a second opinion from an experienced orthodontist (a specialist). I have a feeling that you’re not working with one now.

  6. Stacey says:

    Hi Dr. Jorgensen
    My 8 year old son recently started phase 1 orthodontic treatment of a palatal expander and lip bumper for crowding on both upper and lower. The palatal expander went very smoothly and is not much of a problem for him. The lip bumper, however, is a very cumbersome and clunky device. His teachers couldn’t understand him, it was difficult for him to eat and it just looks very awkward in his mouth. (He also has some sensory issues that we are concerned about) Our doctor offered for him to only wear the lip bumper at night, but it is difficult to tie it in with rubber bands each day and night. We decided to get a second opinion, and the other orthodontist doesn’t use lip bumpers and suggested leaving the bottom alone for now and watching the lower jaw to see if some space opens up–and if he ends up needing the space–to remove his lower baby cuspids (canines). This seemed like a much easier and less obtrusive treatment than wearing the lip bumper for a year or so? How do you feel about lip bumpers? (By the way, I’m also a Wash U graduate!)
    Thank you! Stacey

    • I’m personally not a fan of lip bumpers for the reasons you’ve just described. There are a lot of ways to regain space in the lower arch and I find lip bumpers to be cumbersome

      • Stacey says:

        I very much appreciate your reply. It helped me feel validated in our decision to not use the lip bumper (as well as a 2nd opinion we go in person). Your article was very informative, and I wish I had read it before we started treatment. I hadn’t realized that the lower jaw doesn’t expand, and that it’s only the alignment of the teeth that you can work with. You have a great blog…thank you!

  7. Sarah says:

    Hi! When I first got braces about 6 months ago, they said I had a very simple case. My teeth are now straight and have a slight overbite and I’m wondering if you’ve ever had a case where a patient only needs them on for 6-9 months? Thanks!

    • Sure. Everyone has different issues and sometimes 6 months of treatment can make a nice improvement, especially if you only align the front teeth. The “slight overbite” you mentioned is why most orthodontic treatment from a specialist takes longer. We want to fix the appearance AND the bite. Fixing a bite almost always requires longer than 6 months

  8. Jack says:

    Hi, you seem highly skilled. I have moderate crowding and slight overvibe. I originally wanted braces through my main dentist but he only does invisalign and he said I would not be a good fit for it and I would need metal braces for a 100% smile. I went to western dental for my metal braces and was told no teeth would need to be removed with proper jaw manipulation and spacers and bands that it would be enough. Less than a year in she’s gone and replaced by a new ortho after 6 or more months is now stating 4 teeth will need to be removed to get a perfect smile. The spacer was placed in my upper mouth and with in 3 months teeth perfectly spaced out. I had mentioned if the same could be used for the bottom. He stated that no type of spacers are allowed for adults only for kids. I know I’m not a doctor but I feel if there was a slight chance of using some tool to expand my lower half I would get that jaw manipulation the original orthodontist was speaking of to keep all my teeth. I feel like like removing teeth is a short cut and I’m paying lots of money cash. Please advise if adults truly are not allowed to have types of expanders and if there is, how should I approach the newer orthodontic without offending or undermining his judgment.

    • I cannot diagnose your case for you Jack, but I’ll speak in generalities. First, congrats on going to a specialist for your care rather than staying with your dentist. Second, one disadvantage of corporate dentistry is that you’re going to have doctors come and go. Privately owned offices generally have the same doctor (and therefore the same treatment plan) throughout treatment. Lastly, you only have so much bone. You cannot generate bone in an adult with any type of expander. Sometimes removing teeth is the only way to match the size of the teeth with the size of the jaw. Good luck!

  9. Christian says:

    Hi, I am a father of a 18 years old and 6 months boy who is in an orthodontic treatment for 18 months, after extraction of 4 second milk bicuspids because of lacking permanent ones. The spaces, intended to be closed by elastics, has not closed yet, but the changes on his face are visible.
    He already had deep bite and overjet, and elastics, combined with the action of the bumpers placed on the back of the front upper incisors with the purpose of protect the lower incisors braces, bent the lower arch inward increasing enormously the Curve of Spee. Now he has a very deep bite with no support to his jaws. The upper incisors cover complete the lower!
    In this situation, at his age and the short time elapsed from the intrusion of mandible, do you think is it possible to revert opening the arch with a sagittal appliance on the mandible ? Or only the action of the braces is enough?
    Is it true that the intrusion of lower front teeth from this movement lead to root resorption ?

    • Root resorption can happen to any patient at any time and is not linked to any particular tooth movement. If your son should NOT have had the baby teeth removed and the spaces close and the results look bad, you can always re-open the spaces and place implants. My rule is that if there is no other reason to remove teeth (i.e. crowding or protrusion), I will usually leave the baby teeth and place implants if they every fall out.

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