Invisalign Extraction Correction for Protrusive Mouth: Open Bite Treatment Review

Hello, let me introduce Invisalign extraction orthodontic treatment.

Why is Invisalign extraction orthodontic treatment difficult?

Because it is easy for the molars to tip and for the front-teeth bite to become deeper.

Invisalign extraction orthodontic treatment is successfully completed only when these two points are well controlled.

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During a previous initial consultation, one patient once asked this:

<Do you not have any cases finished by attaching brackets?>

Why wouldn’t I? ^^

Today’s post is for that patient I remembered.

23.01

This patient visited for Invisalign orthodontic treatment two years ago.

What the patient wanted to correct were

Dental asymmetry

The front teeth do not meet across the chewing surface (open bite)

These two issues. A protrusive mouth was also visible in the facial profile.

23.01

The midline of the front teeth is different, and there are scattered spaces in the lower teeth.

23.01

Where did the first premolar that should be in the blue arrow position go?

Yes, it is impacted.

In many cases, orthodontic treatment is only possible after removing an impacted tooth. However, in this case, the impaction depth was quite severe, so there was concern about complications. We decided to make a treatment plan so that the adjacent teeth would not touch the impacted tooth. Fortunately, the left side, where the impacted tooth is located, did not require major tooth movement.

As I mentioned before, when a premolar is congenitally missing, the dental midline tends to rotate toward that side.

That dental midline must be brought back to the center so it matches the face and philtrum.

This patient was the same. The front-teeth midline is rotated toward the side where the premolar is impacted.

23.01

The first premolars in the lower arch are also missing on both sides. So spaces remain, and the teeth are spread apart.

Teeth that are absent from birth are called congenital missing teeth.

In conclusion, three of the four premolars are not visible in the mouth. Two are missing, and one is impacted.

Since a protrusive mouth was also present, in cases like this, if we remove only the one remaining premolar, it is good to proceed with orthodontic treatment as if we had extracted four premolars.

We unfortunately extracted the only premolar that had erupted properly and started Invisalign treatment.

23.05

We carried out Invisalign treatment while using elastics.

23.05

At 6 months into treatment, the extraction space already appears to be about half closed. Even at that time, some of the attachments on the extraction side did not fit well, and there was a tendency for the molars to tip slightly, but we did not immediately remake them.

Even if there are one or two places where the attachments do not fit, we strengthen the attachments enough to prevent worsening tipping and move forward first. If we remake the aligners every time the attachments do not fit, waiting for the new appliance alone takes at least a month each time, so the total treatment period becomes too long. (The approach may differ by doctor.)

23.10

Then, 10 months after the start of treatment, when you look at the occlusal photo, it seems as if the extraction space has closed completely.

23.10

However, you can see that the molars have tipped into the extraction space.

For Invisalign extraction treatment to proceed well without such variables, the aligners must be worn properly for more than 20 hours a day, every day without missing even one day.

At this point, we can no longer delay remaking the aligners, and we also need to upright the tipped molars.

23.10

In some cases, Invisalign is effective for uprighting tipped molars, and in other cases, brackets are more effective.

In this case, because the tipping was severe, we decided to attach brackets for partial orthodontic treatment and upright the tipped molars.

From October 2023, over five months, we partially attached brackets to the molars, placed miniscrews, and used elastics to upright the tipped molars.

24.03

After five months of partial orthodontic treatment, the molars were finally upright, so it was time to prepare for remaking the aligners.

We began making the first additional appliance set, and from April 2024 to December 2024, this is the result after wearing all 34 additional appliances.

The extraction space closed well without molar tipping.

The bite on both sides is good.

24.12

However, the midline of the front teeth is still a little disappointing,

24.12

and a small extraction space remained, so we began making a second additional appliance set.

From February 2025 to June 2025, after wearing all 18 additional appliances, treatment was completed.

The total treatment period was 2 years and 6 months.

25.07

The midline is aligned precisely,

25.07

and the bite shows a tight Class I occlusal relationship.

25.07

The remaining extraction space was neatly finished.

Now let’s compare before and after.

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The corrected midline and improved open bite of the front teeth. Now you can bite into food more comfortably.

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The molar bite changed from the original Class III relationship to a normal Class I occlusal relationship.

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As the protruding upper front teeth were corrected, the protrusion was improved.

Now let’s compare the facial profile.

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As you can see in the photos, orthodontic treatment makes the chin look slimmer. The mouth also looks prettier.

Above all, the lips and jawline, which had not closed naturally because of the protruding front teeth, became more natural.

In particular, in this patient, mandibular autorotation occurred due to molar intrusion, creating the effect of a shorter lower face and making the chin point appear more forward than at the beginning.

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A beautiful smile line stands out.

When smiling, the tilt of the lips is not something that can be improved through orthodontic treatment.

However, if you practice lifting the less-raised corner of the mouth to match the other side, you can achieve smile symmetry.

In fact, flight attendants preparing for work do match the height of the corners of their mouths.

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Beautiful front teeth, beautiful smile

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Beautiful mouth shape

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During the two-and-a-half-year orthodontic period, the impacted tooth was left untouched and remained as it was.

Root parallelism is good.

No root resorption occurred during the two-and-a-half years.

The protruding front teeth moved backward, improving the mouth shape.

What stands out is mandibular autorotation.

As the lower jaw closed more due to molar intrusion, the lower face became shorter and the chin point came forward compared to the beginning.

The combination of improving the protrusive mouth and mandibular autorotation dramatically improves the mouth shape.

We always strive for a perfect result so that the patient’s valuable time, cost, and effort are not wasted.