January 30, 2017

No evidence that orthodontic extractions damage facial profiles.

Early last year I wrote several posts on the effect of orthodontic extractions on facial profile. Since then, this interesting systematic review has provided us with more useful information.

We are all aware of the issues concerned with the need to extract teeth as part of orthodontic treatment. There currently appears to be a trend towards providing more non-extraction treatment. I am certainly surprised to see orthodontists suggest non-extraction treatment for cases with severe crowding. Some people even refer to extraction as “the removal of body parts” or “amputation”! But maybe they need to get out a bit more?

I feel that this systematic review goes some way to providing information that may help resolve our dilemma.

Esthetic perception of changes in facial profile resulting from orthodontic treatment with extraction of premolars


Lared et al

The Journal of the American Dental Association, Volume 148, Issue 1.


DOI: http://dx.doi.org/10.1016/j.adaj.2016.09.004

A team from Brazil carried out this review. Importantly, no member of this group was an orthodontist, so I thought that author bias was reduced. The Journal of the American Dental Association published this paper. This is a high quality journal.

What did they ask?

They did a systematic review to find out if there were any differences in facial aesthetics between patients who had received orthodontic treatment with and without the extraction of four premolars. They also looked at the duration of treatment and whether any cephalometric measurements could help with the extraction/non-extraction decision.

What did they do?

They did standard well executed systematic review. The PICO was;

Participants: Patients who received orthodontic treatment

Intervention: Extraction of four premolars.

Control: Treatment without extractions.

Outcomes: Aesthetic perception of profile, cephalometric measurements, treatment time.

Study design: Clinical trials and observational studies.

They selected only RCTs and cohort studies. They evaluated risk of bias with the Cochrane tool for the RCTs and a variant of the Newcastle-Ottawa tool for observational cohort studies.

What did they find?

After the usual filters, they found one RCT and five retrospective cohort studies.

The studies had three important outcomes;

  1. Aesthetic change measured by rating panels.
  2. Change in soft tissue morphology; measured by several metrics
  3. Duration of treatment.

I will look at these findings more closely;

Aesthetic change

They found that the lay panels preferred the profiles of the patients who had extractions.

Cephalometric data

They found that in patients who had extractions there was retraction of the lips. When they looked at at these measurements more closely they found that extraction retracted the nasolabial angle by 1.4° and without extractions increased it by 3°.

Duration of treatment

Duration of treatment was 7.8 months (95% CI 3.2 – 12.3) longer than none extraction treatment.

Finally, and importantly, when they looked at risk of bias. They classified the RCT  as high risk and I felt that the retrospective cohorts were at moderate risk.

Overall they concluded;

  1. There was no real differences between the changes in facial profile following orthodontic treatment with and without extractions in terms of aesthetic outcome.
  2. If a patient had lip protrusion then premolar extractions were beneficial.
  3. The duration of treatment was longer for extraction patients.

What did I think?

I thought that this was a good and well carried out systematic review. When I interpreted the results I took the following factors into consideration

  1. The studies were done on “borderline” cases. This is a logical step as we all know that some cases are clearly non extraction and others are clearly extraction (most of the time)
  2. I thought it was very important that they considered studies that evaluated laypersons perceptions. This results in greater generality of the findings and conclusions.
  3. I was disappointed to find that the RCT was at high risk of bias. Furthermore, they included retrospective studies and this introduces a degree of selection bias (even though the Newcastle- Ottawa scale rated these studies as being of low/moderate risk of bias). When I bear this in mind I can only conclude that any recommendations on treatment, from this review, are of low/moderate strength.
  4. As I discussed in my post last week on the interpretation of negative findings.  We can only conclude that there is no evidence of a difference in facial profile changes from extraction and non-extraction treatments.

Final thoughts

When I wrote about extractions in my previous posts, my overall conclusion was that extractions are necessary as part of orthodontic care. We should not be afraid of taking this decision. It is also important for us to remember that it is not only the decision to extract that influences the facial profile, the most important influence is likely to be our skill and use of mechanics. This is part of the art of being an orthodontist. As a result, we should not fall into the trap of believing that extractions do harm and adopt non-extraction philosophies too readily.

It is always useful to consider how the results of a study can influence our practice.  When we look at the findings of this paper, we need to remember that the cases in the review were “borderline” extraction.  As a result, I can conclude that there are minimal differences in the effect of extractions on borderline cases (this agrees with the studies by Lysle Johnston). This means that when I see a patient with moderate crowding, I am more likely to do non-extraction treatment, because I prefer not to extract teeth.  When there is mild crowding, I will go non-extraction.  In cases of severe crowding, I am more likely to extract.  This is not rocket science!

Furthermore, we all know that non-extraction treatment is easy.  I cannot help feeling that people promote non-extraction treatment for all cases, as part of a new philosophy or paradigm change, because it is so straightforward. I think that we need to be more cautious.   If we extrapolate some of the findings from this review to the decision to to treat patients with severe crowding on a non-extraction basis, it appears that we could make the profile too protrusive by non-critical expansion.

We can all procline teeth and expand arches to put roots through the alveolar bone and create patients with rictus smiles. In this respect, this review is good, timely and relevant to today’s trend to ignore evidence and follow the paths laid out by the non-extraction gurus, pedlars and quick fix salesman.

Let’s have a good and civil discussion!

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Have your say!

  1. Is absence of evidence, evidence of absence Kevin?

    I agree published evidence is poor overall BUT I am reassured that over the last 2 decades attitudes have certainly changed away from routine extractions of 4 teeth, but NOT because the published evidence suddenly ‘proved’ this but because CLINICAL EXPERIENCE demonstrated this over the years, leading to changed outcomes !!!

    I still have issues with ‘moderately’ crowded cases still being taught or defaulted into the ‘extraction’ category and even still written into the texts of Orthodontic tombs referenced post 2010, which I know Kevin you say that is not what is taught now, but such ‘older’ approaches do still seem to linger IMHO.

    Mixed feelings about your comments upon extraction cases – because whilst they may be ‘quicker’ in many cases than going extraction, but going extraction is seen as a ‘quicker’ way to get space and then just ‘churn’ patients through the standard 18-24month established way of doing things, established over the last 2 decades.

    Couple that with a virtually total withdrawal of teaching Undergrads and GDPs Ortho (Specialist or nothing unlike most other dental sectors such as Perio/Endo/Paedo/OS etc.) and that vacuum/need has been filled by other ‘innovative’ approaches on the high street (every-day) which views Orthodontics as Dentistry and GDPs should be doing most of the ‘routine’ cases and yes, even more of those will become ‘non-extraction’ over the coming years.

    Then maybe in another 10-20 years the published evidence will catch up with real EBM where Clinical Experience and Patient Wishes/Choices lead once again…….

    Yours observationally,


    • Thanks for the comments. I actually think that the change towards more non-extraction has come from a combination of research and clinical experience. I have certainly been aware of conference presentations and publications that have moved orthodontics this way.

      I am not sure where you have the information that moderately crowded cases are defaulted to extraction. This is certainly not taught in most specialist programmes.

      I am not sure if you understand my comments about non extraction being quicker.

      Yes, the vacuum in teaching is being filled, but I would not say that it is being done by innovation. Perhaps a mixture of tailored teaching and Snake oil?

      In my opinion the evidence and practice are interfacing nicely with patient opinion in orthodontics. But what do I know?

  2. Totally agree with your conclusions Kevin. Too much emphasis these days on expand and procline everything. Will be interesting to see what happens perio wise in 20 years time to patients who have had roots pushed through the alveolar bone!

  3. I would agree with your analysis of this review. Extractions per se do not damage the facial profile; however, lack of a diagnosis, poor mechanics and inattention to detail certainly can. There is still a lot of conflation regarding present day Tx goals vs. the past (Tweed, Begg era) in terms of incisor position and inclination. In well-treated extraction cases, once the incisor position is optimized, anchorage is burnt to close the spaces. The other dimension that is frequently ignored is the Transverse – skeletal expansion and extractions are not mutually exclusive and several cases need both modalities.


  5. Kevin, in order to move forward from these ongoing misconceptions regarding tooth extraction as part of orthodontic treatment, we as orthodontists, need to start being more precise with our language if we ever want to have an informed, ongoing discussion about things like mechanics, anchorage etc, the things that really affect the face.
    First, orthodontist need to be clear that “extractions” do not change “faces”. The fact is that Orthodontic tooth movement can have an effect on the lips. More specifically, Changing the position of the incisors can affect the position of the lips. Period. End of story.
    The reality is that all other changes people ascribe to “extraction treatment” are actually a result of choices made by the person managing the case. Choices like which teeth to remove (first or second bicuspids, uni or bilaterally), Lots of anchorage or none at all, can both have a profound effect on final incisor position and thus the lips/face yet this is never part of the discussion. (outside of your comments in this forum )
    The real variable that people should be focusing is the final position of the the upper and lower incisor and how it will differ from the current position.
    If we as orthodontists want to be able to help patients choose a wise course of treatment instead of succumbing to snake oil, then we need to be more precise about the language used when discussing how our treatment decisions and planned tooth movement affect “faces”

  6. Hi Kevin
    Enjoyed your comments.
    I think the profile may be more dramatically affected depending upon the type of bio-mechanics employed in a specific situation.
    Hi or low alpha vs. beta moments in segmental type (“Burstonian”), mechanics should likely be evaluated with the same premise if they have not been done so already.

  7. Hi Kevin,

    Really interesting blog topic and I couldn’t agree more on few of the comments posted.
    I think bio mechanics plays a really important role in all of this and needs to be the central focus of the discussion on extraction vs non extraction treatment modality. It is only then clinicians who are non- orthodontists would understand that extraction of teeth for orthodontic purposes and retraction ( done the right way of course) will not necessarily lead to the lips falling back if proper labial incisor crown torque is maintained during the process. Unfortunately most people mistake retraction for retroclination and so in what you may be picturising as an ideal end result post four bicuspid extraction and fixed mechanotherapy in a moderate crowding case ,someone else maybe imagining a totally different facial profile with an increased nasolabial angle.

  8. The more I have learned working in a non-extraction based office is overwhelming in the argument of saving versus pulling!! Unfortunately most cases of extractions on patients in their early or mid teen years later in life present with constant TMJ problems. As the new patient coordinator for a high end alternative based office or Dr was European trained about the importance of airway,function, and esthetics, but most importantly jaw orthopedics. Time and time again we see adult patients who grind or clinch their teeth, my first question to them are “did you have any teeth removed or have braces”? Unfortunately 9 times of 10 these brutalized adults had no clue that what was done to them as teens would cause such caos. I’m not a Doctor but have seen adults with jaws of young children and how can that be told it is ok? This concept is an easier way to do a job that yes will be quicker, but doing jaw expansion with palatal expanders, starting at an early age is also key to help assist healthy jaw growth. Our office we like to start with jaw expansion around the age of 6 and 7, it is with the child growth we are working with. It is not against nature by pulling teeth back in to place, but working with them to help form new healthy jaws. Years and years of learning has brought to me to the point where I do now stand behind the fact that extractions of healthy teeth is never recommended!!!

  9. Extractions ruin the face. We know you’ve been severely brainwashed. You’ll look like a pancake after bicuspid extractions, they completely flatten out the face & make your nose longer. I’ve never seen anything like it.

  10. Dr. William M. Hang is a hero for exposing the truth on retraction orthodontics.

  11. This is a shocking review and study.

    It is obvious to anyone who has actually had this procedure done that it has ruined their face.

    As a person who has had such a procedure I feel this study is pure insult and am deeply offended by orthodontics defending this procedure.

    I hope that at least orthodontics giving out this advise give fully informed consent on this procedure before removal of teeth and make clients aware of their options.

    I feel if they did so that most people would get a second opinion and this awful practice would go the way of the dinosaur where it belongs.

    As someone who has suffered at the hands of this bad dental practice I have a right to speak. I had a right not to have my face disfigured and my anger is proportional to the pain I have suffered at the hands of this practice.

    I am appalled at this study defending this practice and feel it is a distraction from the real threat of litigation that would occur as the obvious visual results speak for themselves if anyone views the results.

    That they are midline cars should automatically exclude the study from relevance as it is well known that the cases of most crowding is where and when the damage is most obvious.

    Addressing the reasons why under development of the jaw occurs should be first line in medical and biological dental care as well as early nutritional and development concerns address when it does occur.

    I would greatly apprise if the author of this site would let my opinion stand.

    Anyone reading this I suggest you familiarise yourself with the work of Weston Price and his original work of the societal and nutritional implications of why dental arches do not fully form.

    Best regards.

  12. To the non-extraction advocates: Can we acknowledge we have all see extraction cases that yield beautiful, pleasant, stable smiles that did not ruin the patient’s face? Ever wonder why that is?…

  13. This study sounds idiotic. I had retractive orthodontics. My jaws were pushed into my airway. Since then, I’ve had horrible headaches, TMD, and occipital pain. I also have sleep apnea. It also made my nose longer and gave me a dorsal hump and turned me into a mouth breather. Thank goodness my orthodontist was not informed enough to do extractions. I am currently doing expansive orthodontics/orthotropics. My TMJ feels better and I have more space for my tongue. Whoever wrote this study needs to be shot in the jaw.

    • Observations of wild animals and indigenous people prove that the only thing a child needs to do to align all 32 teeth is to use both hands to chew ROUND APPLES with incisors, ROLL ROUND CARROTS between premolars, and chew with attention to how the food is aligning upper teeth with lower teeth. Most children are distracted. and using a fork and knife does nothing to align teeth, or stimulate bone growth.

      CHAD is honest: replace the orthodontists with SQUIRRELS who are expert chewers for alignment of their incisors and molars! None of the ortho studies are independently endorsed by pulmonologists, gastroenterologists, ENTs, Neurologists-spine, and biomechanical experts.

      Biomimicry chewing!

  14. Extractions ruin your face , no one likes to look at long flat looking faces. It’s just common sense not to extract teeth . We need our teeth for a reason , looking back sounds barbaric to extract teeth. Orthodontist will try Thier hard to ignore this and make false claims. There is certainly evidence.

  15. I had Extractions with my braces Orthodontists treatment. Now I’m seeking either MSE or DJS to fix my face and to improve my tongue space / breathing. I was class II and my Orthodontists was extremely incompetent. Taking out teeth for braces treatment is not something that should be taken lightly. Everything should be taken into account. We are not living in the 18hundreds now. We have education and hopefully medical professionals make use of it sooner rather then later.

  16. Same, extractions per se do not cause damage to the face but pulling the teeth back to fill in the extraction spaces does since it makes the arches narrower. Happened to me, my cheekbones which were prominent before have now completely flattened, my eyes look tired and droopy, my nose looks unnatural, asymmetry is exaggerated and my face looks narrower and ugly. There is a striking difference between my before and after photos. My face was completely ruined. What’s worse my orthodontist thinks he has done nothing wrong, arrogantly claiming moving teeth does not affect the face at all. Orthodontists are very bitchy about this when confronted for some reason. It’s common sense that if you were having problems with small arches and by extracting and retracting you make it even smaller, you are bound to have your case worsen. Simply warning me about the changes retraction can cause to my face would have been sufficient. I could have lived with crooked teeth.

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