The role of orthodontic extractions (pulling teeth out for brace treatment) is one of the longest running controversies in dentistry. Some sensational media reports relating to orthodontic extractions have created long standing divisions between dentists. There is unlikely to be agreement in this area any time soon.
The start of the trouble
Modern orthodontic practice is now firmly based on scientific evidence but in the early days a strong opinion by an influential doctor was all that was needed to establish an entire school of thought. Statistics and computing did not exist so well meaning ignorance was practiced. The dispute over orthodontic extractions arose about 80 years ago when two doctors developed opposing philosophies. One chose ‘never to extract teeth’ and the other ‘always extract teeth’. Both were wrong. Neither doctor thought the attributes of the individual patient were important. Both approaches worked for some people but would fail for others.
Who might need teeth extractions for orthodontics?
Extraction of teeth is OK for people who have noticeably protruding teeth with full lip profile e.g. Chinese, Japanese and many Afro-Americans. Most caucasians have much flatter lip profiles and suffer noticeable thinning of the lips in older age. So to avoid making (whitish) people look old before their time we believe it is wise to avoid mid arch extractions for patients with flatter lip profiles. Of course there are exceptions to all stereotypes so it is important to carefully assess each and every person.
“As an orthodontist in Sydney I have been confronted on several occasions by dentists asking me what proportion of my cases I take teeth out of. The only correct answer is 100% of patients who need it and 0% of those who don’t – but its a daft question”
Can extraction of teeth damage my face, smile, jaw joints etc?
Cynical marketing by some orthodontic practices and dental practices have claimed orthodontists who order extractions damage the face and create a multitude of problems. The same hypocritical orthodontist who appeared on 60 minutes some years ago making these sensational claims orders extractions for individuals with ‘asian teeth’ – he told me personally! Properly planned and performed orthodontic treatment does not damage the smile or face and all trained orthodontists know this.
“A few years ago I did a fun little test to see whether specialist pediatric dentists could tell whether a selection of different patients had had extractions during orthodontic treatment from photos of their smiling faces. The average correct score was around 50% which is the same as marking the paper in an entirely random manner. Even highly trained dentists cannot tell the difference between extraction and non-extraction orthodontic results”
The 7 proper purposes for orthodontic dental extractions
To relieve significant overcrowding of the teeth (>7mm ), teeth may be extracted to give the most stable alignment of the teeth.
To provide space to permit the teeth to meet properly when there is a mild imbalance in the jaw sizes
To prepare for certain types of jaw surgery
To remove dodgy teeth and close the space is often better than patching things up and may be cheaper than keeping bad teeth for a lifetime.
Extraction orthodontics’ can often provide the space for the emergence of the wisdom teeth. that may otherwise require extraction.
Which teeth are taken out?
Usually the teeth are chosen for the extraction space to get the best final tooth positions. Sometimes, adjacent heavily repaired teeth are extracted instead. Under these circumstance the use of mini-implants may be required to obtain the most ideal outcome. The further forward in the mouth teeth are extracted the larger effect this has on the position of the front teeth. Normally the extraction spaces will completely close during the orthodontic treatment. Occasionally some space may remain if there is insufficient bone width at the extraction site or if the orthodontic treatment is not completed. This can occur if there is a delay in starting space closure following the loss of the teeth.
Are there other methods of space creation?
There are other methods to obtain space for tooth alignment and tooth movement in the crowded dentition, and the options are as follows:
Push the back teeth backwards (into the wisdom teeth space) using implant anchorage
Dental arch expansion is a good treatment choice to align spaced or mild to moderately crowded teeth. Often as a result the smile width is a little wider and the teeth positioned slightly further forward giving enhanced support to the position of the lips- an appearance that is regarded by many people as desirable. Non-extraction treatment can take longer and requires a bigger commitment to retainers compared to the alternative treatment involving tooth extraction. About 85% of caucasian patients can be treated without extractions but of the proportion in Asian patients is lower.
Interdental Stripping: up to 1/2 mm of enamel can be filed from the adjacent surfaces of teeth to provide incremental space to improve the stability of the completed alignment. This method is also valuable to assist alignment of triangular shaped teeth and to disguise triangular gum spaces in the older patient following alignment of crossed over teeth.