Orthodontic Extractions

Possibly no area of orthodontics is more fraught with controversy than extraction.  Although extractions should be avoided when possible, Dr. Bentele believes that adherence to well founded principles presented in a common sense way alleviates any unease in this area.  Excellent orthodontic records are a key component to decision making and aid the visualization of an excellent outcome.   Non extraction or extraction therapy is not the goal of orthodontics – an excellent smile with stable, healthy teeth are the goals.  Overexpansion in a valiant but unwise attempt to fit all of the teeth into too little space is not “Conservative” treatment.  The costs are many for such a path: extra time and expense; strained gum tissue prone to recession; protruding lips; lips unable to close comfortably; a strained appearance of the muscles around the mouth; teeth expanded beyond stable positions; and impacted 2nd molars that require extraction.   Here are some examples of what researchers have discovered about some myths that have grown up about orthodontic extractions:

Extractions will “dish” in the profile

Johnston, University of Michigan
Extraction and non extraction patients were equally pleased with their facial appearance
Excess lip protrusion is reduced in extraction cases.

Extractions will cause jaw joint problems

Johnston, University of Michigan
No evidence that the jaw joint is pushed back in extraction cases or that extraction patients have any higher rate of joint problems.

Extractions are undesirable because every tooth should be preserved

Kim, Seoul University
Nonextraction patients were more likely to experience impacted wisdom teeth.  Impacted wisdom teeth are often associated with pathology and have to be extracted.  Even the 12 year molars can be impacted and lost by pushing the teeth posteriorly in crowded cases.

Non extraction treatment leads to a wider more pleasing smile

Gianelly, Boston University
Virtually no difference between the smile width or the attractiveness when extraction and non extraction groups were compared

What questions are used to decide if teeth need to be extracted for orthodontic alignment?

  1. Is the crowding due to a truly narrow arch width? → expand

  2. Is the crowding moderate in a growing patient? →preserve leeway space with a lower lingual holding arch

  3. Does the patient have difficulty closing their lips over their teeth and the mentalis muscle in the chin looks strained? → extract

  4. Is there enough crowding that the permanent teeth will have difficulty erupting into a desirable position? →Consider serial extractions

  5. Is the gum tissue thin with minimal overlying bone in areas of crowding? → In moderately crowded cases consider a gum graft to increase the thickness.  In more crowded cases extract to protect the gum tissue.

  6. Do the lips protrude beyond a line drawn from the tip of the nose to the chin? → Consider extractions but consider how that fits into other facial characteristics.

  7. Are the lips thin and retrusive? → avoid extractions

  8. Is the vertical overlap of the incisors deep? → avoid extractions

  9. Is there an anterior open bite – the incisors are not in contact?  Aligning crowded teeth will worsen this problem → extract

  10. In addition to crowding, do the top incisors protrude excessively beyond the bottom incisors? →extract to not only align the teeth but to also bring back the protruding incisors.

  11. How much do the incisors angle outwards?  If the incisors are already angled outwards, pushing them further will increase the likelihood of gingival recession and instability.  Long term retention of the orthodontic treatment will be difficult. → extract

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