Written for colleagues. Komura Pediatric & Orthodontic Clinic, Toyonaka, Osaka, Japan. Practising since 1995; treating with clear aligners since 2012.
This page is not a patient page. It is an account of how we reach a decision that cannot be reversed.
1. The goal is not a straight line of teeth
We work toward what we call an individual normal occlusion — the occlusion that belongs to that person’s skeletal pattern, not a standard arch form imposed on it.
This matters because the goal determines the treatment. If the goal is a perfectly aligned arch photographed from the front, then space must be found, and extraction becomes the obvious way to find it. If the goal is a functioning occlusion in a face that still looks like that person, the question changes: how much room does this patient’s bone actually have?
The face, the profile, and the airway are part of the result whether or not we planned for them. We prefer to plan for them.
2. Extraction is a design decision, not a diagnosis
An extraction is irreversible. The moment it is done, part of the design space closes permanently, and every later decision is made inside what remains. We therefore treat it as the last decision to make, not the first.
Before deciding, we want to know two things that a study model cannot tell us:
- Where the alveolar bone actually ends. We take CBCT and look at the labial and lingual plates. The limit of safe movement is the bone, not the crown. A tooth can be aligned and still be moved out of its housing.
- Where the incisors sit relative to the skeletal base. Cephalometric analysis tells us whether the crowding is a tooth-size problem, an arch-size problem, or a skeletal one. These three look similar in the mouth and require different answers.
Only after those two are known does the extraction question have a real answer. Asked before, it is a guess dressed as a plan.
3. What we use instead, when the bone allows it
In growing patients, the most useful lever is time. If the base itself can be developed while growth is available, the crowding problem is smaller by the time it would have needed a decision. We work on arch development, oral function and habits, nasal breathing and lip seal — not as an alternative to orthodontics, but as the groundwork that decides how much orthodontics will be needed.
In patients who are no longer growing, the levers are different: sequencing, expansion kept inside the bone, distalization, interproximal reduction kept inside enamel, and skeletal anchorage with mini-screws where the reaction force would otherwise be paid for by teeth we want to keep still.
None of these is a technique we own. What we think matters is that the amount of movement is decided before the first movement, and that the plan can be inspected — including root position and its relationship to bone — rather than discovered while treatment is under way.
4. Sequence, and why we avoid jiggling
Root resorption and gingival recession are not caused by movement as such. They are associated with repeatedly reversing the direction of force on the same root — moving a tooth out, then bringing it back, because the plan changed midway.
This is a sequencing problem before it is a force problem. When the sequence is designed in advance, a tooth can be moved once, in one direction, with light continuous force. When it is not, the same tooth is corrected several times, and the root pays for it.
We would rather spend the time at the planning stage.
5. When we do extract
We do extract. A clinic that treats non-extraction as a rule to be defended has stopped treating the patient in front of it. These are the situations in which we decide to extract:
- When the incisors cannot be placed within the alveolar housing without extraction. If achieving alignment would require the roots to leave the bone, the alignment is not worth it.
- When the extraction is part of a surgical plan, decided together with the surgeon rather than as a way of avoiding surgery.
- When the profile would be made worse. Lip protrusion that the patient is unwilling to live with is a legitimate reason, and it is the patient’s judgement to make, not ours alone.
- When a tooth is already compromised — severe resorption, poor prognosis, a tooth that is the obvious one to lose.
What we do not do is decide extraction because it makes the case simpler to finish, or faster.
And we do not camouflage
Where the discrepancy is skeletal and beyond what tooth movement can address, we do not disguise it with tooth movement. The honest answer in those cases is orthognathic surgery, and we say so and refer.
Tipping teeth to conceal a skeletal relationship spends the patient’s dentition on the appearance of a correction. It can look acceptable in a frontal photograph while leaving the underlying relationship, and often the function, where it was. We would rather tell a patient that what they want cannot be achieved by moving teeth than deliver something that resembles it.
If a patient declines surgery, we set out plainly what can and cannot be achieved without it, and we let that decision be theirs — made with the limitation stated, not with the limitation hidden inside a treatment plan.
6. What we tell patients before they agree
Designing without extraction generally takes longer. It depends heavily on wear. It usually requires more refinement stages, and we continue those to the end rather than stopping at “close enough.”
We say all of this before treatment, not during it. A patient who was told the cost in advance stays with the plan; a patient who discovers it midway is entitled to feel misled.
We also try to present findings as options rather than as warnings. “If we act now, these choices remain open” is both more accurate and more useful than telling a family what they have already lost.
7. Why we took an aligner-only path in 2012, and stayed on it
Not because appliances carry prestige. Because of one property that matters to the decision described above: the movement can be designed, examined and adjusted before it happens, including the position of roots relative to bone.
Fixed appliances are the older technology, and we say that plainly as a technical matter — it is not a judgement of the clinicians who use them, many of whom achieve results we respect. But when the question is whether a root will stay inside its housing, we would rather answer it on the plan than discover it on a radiograph two years later.
Our cases have been listed on the Align Global Gallery since 2018 — a venue where cases are reviewed before they appear. We mention it not as a ranking but as a record of continuity: it is where our work can be inspected by people qualified to disagree with it.
8. What we would like to hear
We are one clinic in a suburb of Osaka, and we do intend to grow — from five chairs to eight. Not into a chain: into the largest size at which the same standard still reaches every chair. What we will not do is grow by making the work simpler.
Alongside that, we are trying to be wrong less often, and to write down our reasoning clearly enough that another clinician can use it — or show us where it fails.
If you design cases differently and think our reasoning is mistaken, we would genuinely like to know. That is more useful to us than agreement.
Komura Pediatric & Orthodontic Clinic · 5-14-4 Nakasakurazuka, Toyonaka, Osaka 561-0881, Japan · komura-ortho.jp
This page describes how our clinic approaches treatment planning. It is not clinical advice for any individual patient, and outcomes differ between patients. Treatment decisions require examination and diagnosis.