Is it possible to intrude teeth without an anchorage device?

[que2]

I’ve seen a few examples online of people whose orthodontists were using regular braces (and even invisalign) to intrude their upper row of teeth, without any mention of an anchorage device like TADS (or explicitly stating that no anchorage device is being used).

How is this possible? Is a small amount of intrusion – let’s say between 1mm minimum and 3mm max – possible without an anchorage device, using only braces? Can this amount of intrusion only be achieved with the front six teeth, or can you expect stable movement of the molars as well? (that won't relapse). If some relapse is unavoidable, how much is to be expected?

Does the gum line move with the teeth? I’ve heard before that attempting this kind of intrusion, even if it's minor, is unstable, unsafe, leads to bone loss, bunches up the gum in an ugly way, etc. and I wanted to get a final opinion on this forum. When I first heard that small amounts of intrusion can be done without surgery I really wanted to learn more, but I don't want to get my hopes up either.

[ItsFreyja]

Hi que2! Yes, the molars can be used to anchor a small-to-medium amount of incisor intrusion. This is very common. The usual mechanics range from bracket placement to reverse curve wires and specially bent or segmented intrusion arches. Obviously, since the molars are the anchors, they won't intrude themselves, and the premolars won't intrude much if at all. If your molars especially need intrusion -- if you have an open bite -- this won't be an option for you.

All of the horrors you mention aren't normally an issue with minor incisor intrusion, which, again, is really quite common. But as far as a "final opinion" goes, you won't get one on the internet. Go see some orthodontists and see what they think. Ask to see pictures of similar cases that they've treated.

[que2]

Hi Freyja - thanks for the reply! How much incisor intrusion is possible with the methods you listed? (was the 1-3mm estimate I gave realistic?)

Are you saying that any intrusion of the molars and premolars is impossible without an anchorage device? What about with an anchorage device? Then how much intrusion can you expect? (once again, is 1-3mm too unrealistic, and is it usually stable if there's a retention period?). Does the total cost of treatment increase significantly with the use of anchorage devices?

I don't have an open bite. This would mostly be for cosmetics.

[ItsFreyja]

Anything more specific than what I've already said is going to depend more on the particulars of your case than anything. 1-3mm intrusion of the incisors sounds quite reasonable to me, but how much is possible and aesthetically pleasing depends on various factors. Moving molars vertically requires anchorage and can be unstable depending on what forces originally led to their overextrusion. The cost of TADs seems to vary pretty widely. I would encourage you to go have a couple of consultations with local orthodontists to get opinions that are actually relevant to your own case; not all of them have a lot of experience with TADs yet, so make sure you talk with someone who does. Ask to see before-and-after pictures of similar cases.

I can tell you about my case in progress. I had a 70% overbite that will be corrected primarily through incisor intrusion with a bit of premolar extrusion; I also have a gummy smile (5 mm of gingival display while smiling) due to vertical maxillary excess that is only of cosmetic concern.

All the orthos I consulted with felt I would be a good candidate for a Le Fort I impaction, but I have never seriously considered doing the surgery. As an alternative, my ortho proposed placing 4 TADs in the labial surfaces of the maxilla to fully correct my gummy smile by intruding the entire upper dentition. He charges $250 per TAD placement. I seriously considered doing this and did a lot of research on the subject, but I have opted against it.

Six months into my treatment, I have achieved about 2 mm intrusion of my upper central incisors just through bracket placement. My lower 4 incisors are in the process of intruding about 2 mm through bracket placement; they are taking longer since I have more crowding in the lower arch. My ortho is planning to install a reverse curve wire in my upper arch at my next adjustment to achieve the remaining intrusion necessary to open up my bite. While all of this will not yield as dramatic results as I might have gotten surgically or with TADs, I am expecting to be quite pleased with my new smile!

[que2]

I’m glad to hear that your treatment is going so well! I think what you described – moving the front six teeth up a bit to reduce the appearance of gumminess – is something I would be interested in. Did your gumline move with your teeth? I don’t show as much gum as you when I smile, so I feel like my case might be easier to treat. I like how much of my front teeth show when my mouth is at rest, so I’m wondering if it would be possible for an orthodontist to leave the placement of the front two teeth alone and just move the teeth around them up a bit.

You said that moving molars vertically can be unstable depending on the forces that originally led to their overextrusion. What do you mean by this? What if your molars aren’t overextruded? (Is that just another word for too long?). Then can you do a small amount of intrusion for cosmetic reasons? If it was just for cosmetics I would only intrude my four premolars because the molars in the back of my mouth don't even show when I smile, but I’m worried about how that could affect my bite (I’m guessing you’d have to move the back molars a bit too or else your bite could get weird - how is your orthodontist handling this issue? Is he just using a curved wire?)

Why did you ultimately decide against getting TAD’s? I’m really curious.

Are you intruding your lower incisors for cosmetic purposes? I’m worried that by moving the upper dentition, this could make my lower row of teeth show more when I speak or smile. Is that a problem you’ve encountered? I’m not sure if the amount of intrusion I’m looking for is big enough to cause any noticeable differences in how my face/lips look, but are you expecting to see any change? Are you worried about how the intrusion will affect things like the placement/shape of your lips? (I only ask because I’ve heard that the soft tissue of your face and your teeth are linked, so altering one could impact the other).

Sorry for so many questions. I understand that I have to eventually seek a consultation with an orthodontist. I just wanted to ask my questions on here first, so my expectations are more realistic when I go in.

[ItsFreyja]

Let me try to answer all of your questions; it's going to be jumpy.

I should mention first that if you have a normal amount of incisor display at rest (2-3 mm), you may be barking up the wrong tree altogether. It's possible that you could be better and more easily served with lip repositioning, Botox, or cosmetic laser gingivectomy. That said....

My gumline has moved up with the teeth, yes. I have seen gnarly pictures of bunched-up gums in cases of extreme (TAD-driven) intrusion but I'm nowhere near that, so it's looking great. You can see my progress pictures in my thread on the Our Braces Stories board ("Metal braces for a crowded, gummy smile").

What kind of intrusion would work for your smile is massively dependent on a ton of other factors -- the depth of your bite, the depth of your curve of spee, the depth of your smile arc, the amount of incisor and gum display at rest vs. smiling. I really can't speculate further on whether molar intrusion would be necessary or even appropriate for you except to emphasize that it would require external anchorage. My mention of molar overextrusion and intrusion stability was more in the context of open bite cases, which is where most of the good information about vertical molar movements comes from.

In my own case, we are not really correcting my vertical maxillary excess, just camouflaging it by moving the front 4-6 teeth up through bracket placement and reverse curve wires. I had several reasons for opting not to do the TADs. First, my posture all along has been "let's see how much improvement we get without TADs first," and six months in, I am really happy with the amount of intrusion that's been achieved without them, and I know there's still more to come. Second, intruding the entire dentition is slow, slow work and would have added at least another 4-6 months to my treatment, which I didn't want. Third, I didn't want to assume the risk of possibly needing crown lengthening surgery or gingivectomy, further lengthening my treatment time and cost. Finally, I had a good deal of trepidation about changing my face at my age; I think my cheeks would look noticeably droopy if my teeth moved up but they didn't.

My lower incisors have overextruded in the last few years due to some orthodontic work I had done 15 years ago, and fixing them will help open up my deep overbite without much impact on the gumminess situation. When the upper premolars/molars are moved up, yes, the mandible rotates up and forward some to meet the upper teeth, but just doing the incisors won't cause this to happen. I don't think the small amounts of intrusion we're talking about are likely to have much impact on lip shape, either. I'm actually hoping for a slightly fuller looking lip due to the straightening and uprighting of my crowded premolars, but I won't be able to really tell until the braces come off.

Final thoughts: Orthodontists have extensive training and experience with how to improve your smile dynamics. There are a lot of factors to consider, both functional and aesthetic. The teeth still have to meet in a working bite, of course. Less obviously, for example, too much upper incisor intrusion can flatten the smile arc, which is unattractive. Orthodontists excel at visualizing tooth movements, weighing the effects of one movement on another, knowing what are the more and less important components of a pleasing smile. Take everything I've said with a huge grain of salt until you get a professional opinion from someone not on the internet.

[lilyflower]

Sure it's possible but it depends on how much intrusion is being aimed for and what else needs to be done. I have Invisalign and my plan does call for some minor intrusion for a deep bite but nothing huge. Only an ortho can tell you for sure and it also depends on what you're aiming for - if you're looking for absolute perfection some kind anchorage might be needed - if you're looking just looking for an improvement it might not be necessary to have TADs.

[que2]

Freyja - first of all, thank you for such a detailed answer. This was a lot of good info. For a little while I considered if a lip repositioning or botox would be better suited for me (since the change I want is so minor), but I’ve heard a lot of negative things about lip repositioning. Finding any info on lip repositioning online has been difficult, and it seems like the procedure costs the same as braces (minus the benefits of fixing kinks with your teeth and bite of course), has a high rate of relapse, and runs the risk of making your lip look static when speaking and smiling; correct me if I’m wrong on any of these. For botox, I didn’t like how it needs to be redone every few months.

It’s good that your gumline moved with your teeth. That was one of the things I was most curious about. I tried to check out your pictures but I couldn’t access them. After your explanation though, I understand why you didn’t want TADS. I don’t have an open bite, so I guess I would need to consult with an orthodontist before even beginning to wonder what could be a good option for me. The thing holding me back is that I feel embarrassed about setting up a consultation for mostly cosmetic reasons. For the mild functional stuff, I could comfortably wait years without doing anything. I haven’t had orthodontic work done since I was a little kid, and I feel awkward with the idea of going in and telling the orthodontist “I know it isn't medically necessary, but this is what I want my smile to look like” and then seeing if they can do it.

Anyways, thank you for such informative answers!

[que2]

Lilyflower – what do you mean by minor intrusion? How much intrusion are you expecting with your case? Are you only intruding your front six teeth, or all of your teeth? How is your orthodontist doing intrusion with just invisalign?