Extraction versus Non-extraction

The debate about pulling teeth for braces has been going on for over 100 years. This website will not attempt to resolve this issue, but merely attempt to explain the debate and offer an opinion based on the available literature.

Why are teeth sometimes pulled for braces?

The necessity of extractions in a particular patient is most commonly a result of inadequate space availability in the dental arch. The crowding can be so severe in some people that entire teeth are blocked out of the arch. In those cases, the need for extraction is more obvious than in other patients. There are also times where it may be possible to fit all of the teeth into the arch with the braces and align the teeth, however, doing so may be at a detriment to the stability of the teeth, the gum tissue, or the esthetic appearance of the teeth or soft tissue. For example, in a patient that already has excessively flared front teeth (incisors), forcing these teeth further forward to fit in additional crowded teeth would flare them even further. It is well known that teeth forced too far forward may be more susceptible to relapse, and would ultimately give an unesthetic result

Other reasons for extraction could include bite correction, midline correction, or soft tissue/profile improvement. The decision making process can be quite complex, and all of the information gathered at the records appointment needs to be taken into consideration prior to making a final decision. Generally, the bite, midlines, amount of crowding, position of the jaws, position of the teeth, future potential for growth, sizes of the teeth, soft tissue/profile, and other attributes are analyzed to determine the best treatment course.

Some people assert that braces should always be done without pulling teeth. The rationale for this approach generally revolves around their notion that by pulling teeth, the profile and the smile are adversely affected - either by "flattening" the profile or by narrowing the appearance of the smile. Claims have also been made regarding the relationship of TMJ problems and extractions. However, the non-extraction treatment philosophy does not have a strong scientific basis. Many of the studies published supporting this notion are case report type studies, or opinions written in textbook form, which do not provide adequate substantiation of their claims (i.e. Witzig J W, Spahl T J. The clinical management of basic maxillofacial orthodpaedic appliances. Littleton, Mass.: PSG Publishing Co Inc, 1987).

In fact, there are numerous studies that contradict these claims. The studies have shown that extractions done appropriately will provide stable alignment of the teeth, and will not adversely affect the profile, smile, or TMJ: (J Am Dent Assoc. 1995 Jun;126(6):769-72) (J Am Dent Assoc. 1999 Aug;130(8):1173-81) (Angle Orthod. 1993 Winter;63(4):257-72) (Am J Orthod Dentofacial Orthop. 1992 Jul;102(1):1-14) (Angle Orthod. 2003 Feb;73(1):36-42) (Angle Orthod. 2003 Aug;73(4):354-8) (Am J Orthod Dentofacial Orthop. 1997 Dec;112(6):639-44) (Am J Orthod Dentofacial Orthop. 1994 May;105(5):444-9) (Am J Orthod Dentofacial Orthop. 2005 Oct;128(4):450-7)

In summary, it is every orthodontists goal to improve the alignment and esthetics of their patients teeth. In some patients, due to their dental or facial characteristics, this may necessitate either extraction or non-extraction of teeth. There are currently no scientific studies that show extractions in the properly diagnosed patient to be harmful for the smile, profile, or jaw joint. In fact, studies have shown that extraction can improve the profile and smiles in patients that require extraction.