This month, Saba Qureshi explores the long-standing debate about whether or not teeth should be extracted during orthodontic treatment.
Before all the avid Shakespeare fans come, I realize it’s not The phrase, but with humor this time, while exploring the old orthodontic argument of “extraction versus non-extraction” treatment.
Since the introduction of braces, professional opinion on this topic has shifted from one extreme to the other, and it remains a hotly debated topic to this day.
So why is it so controversial?
Well, mainly because many claim that extraction treatment has a potentially negative impact on the facial profile, while others worry that non-extraction treatment does not impart post-treatment stability – and so the battle continues…
Let’s examine the argument in more detail:
Concerns about mining
The main concerns regarding orthodontic exports are:
- Face Profile – those opposed to orthodontic extractions claim that the removal of premolars results in a hollow facial profile, without lip support, which is considered unattractive
- Oral corridors – some clinicians believe that extraction of maxillary premolars causes narrowing of the maxilla, resulting in wider oral passages
- Temporomandibular joint disorder (TMD) – it has been claimed that one of the side effects of premolar extractions is TMD
- Air Duct Dimensions – concerns have been raised that extraction of premolars may result in reduced airway dimensions.
However, much of the literature does not support the above claims…
Are these concerns valid?
Studies comparing orthodontic extraction and non-extraction cases with respect to arch width have found small differences that are not statistically significant.
Regarding the effects of soft tissue extractions on the facial profile, the results are not surprising. It is reported that, in the case of a convex profile with an acute nasolabial angle, extractions may provide some soft tissue benefits. But where there is an obtuse nasolabial angle, extractions may have a deleterious effect.
It has also been reported that the flattening of the facial profile during treatment and long-term follow-up is mainly due to maturational changes, rather than as a result of orthodontic extractions. It all comes down to careful treatment planning for each individual case, taking into account the dental and personal aspects of a patients malocclusion.
Where cases have been carefully designed, it has been shown that even dental professionals cannot detect whether or not orthodontic extractions have been performed based on the facial profile alone.
Oral pathways resulting from narrow arch widths are not a common outcome of extraction treatment even when proper planning has been applied.
And finally, there is no evidence to suggest a significant variation in condyle positions before and after extraction therapy that could lead to TMD.
Orthodontic extension methods
Expansion has been used to correct posterior bridges since 1860, making it one of the oldest means of creating space within dental arches.
It can be divided into three categories:
- Slow maxillary expansion (SME) uses lighter forces for a longer period of time to expand the maxillary arch due to dentoalveolar changes. Slow expansion has been found to promote greater post-expansion stability if given a sufficient retention period. It offers constant physiological force until the required expansion is achieved. SME produces more consistent results when the maxillary arch is slowly expanded at a rate of 0.5-1 mm per week. The most common SME devices used in the UK are the quadhelix and the Damon system
- Rapid rapid maxillary enlargement (RME) involves separation of the interpalatal suture and movement of the maxillary shelves away from each other, causing skeletal expansion. Proponents of rapid maxillary expansion believe that it results in minimal tooth movement (tipping) and maximum skeletal movement. An increase in maxillary arch width of up to 10 mm can be achieved with RME at an expansion rate of approximately 0.2-0.5 mm per day. RME devices tend to be delivered with teeth (eg Hyrax device) or teeth and tissue (eg Haas device)
- Surgically assisted rapid palatal extension (SARPE) reduces the resistance of the closed interpalatal suture for the correction of maxillary stenosis in skeletally mature adults with surgical separation of the maxillary sutures. The following have been reported in the literature as indications for SARPE, all of which apply to a skeletally mature patient with a contracted upper arch. Recommended for adult patients requiring transverse dilatation greater than 5 mm. The rate of expansion produced is of the order of 0.5-1 mm per day.
Non-mining concerns
Now let’s look at the main concerns about non-extraction extension treatments:
- Stability – Some are concerned about the lack of post-treatment stability in non-extraction cases
- impact – Without orthodontic extractions, some claim there is a greater chance of third molar impaction
- Dehiscence – Complications of extension include the risks of creating a split as a result of overextension.
Again, the literature offers conflicting views on post-expansion stability and impact, depending on which article you read. Obviously, there is room for further research here.
Regarding the risk of fragmentation, careful planning of individual cases should be avoided.
Public perceptions
It is safe to say that there has been a steady decline in the popularity of orthodontic exports over time. In my opinion, this is driven not only by the clinical preferences of individual orthodontists, but also by public opinion about exports.
Patients and parents often worry about tooth extraction because they worry about:
- Painful exports
- Aesthetics of mining sites initially
- Removal of healthy permanent teeth
- Damage to their facial aesthetics
- Narrowing of the smile
- The extraction spaces do not close completely.
These fears have been fueled by “horror” stories shared freely on social media by influencers.
At the risk of sounding my age, the only influence I would like our patients to have is that of well-informed clinical decisions.
Considerations
Occasionally, I will apply a “curative diagnosis” for borderline cases that I start without extraction, knowing that extractions may need to be done after the initial alignment.
But this, of course, comes with an increased duration of treatment and perhaps turning of the teeth, so it should be carefully considered.
Ultimately, the decision whether to prescribe orthodontic extractions should be made on an individual basis after a thorough evaluation of crowding volume and space requirements, overjet size, torque requirements, and facial aesthetics.
Catch up on past Straight to the Point columns:
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