October 29, 2018

Are UK Orthodontists prescribing fewer extractions?

There has been discussion on the role of extractions as part of orthodontic treatment since the dawn of time. This recent survey reveals interesting perceptions of UK orthodontists on their recommendations to extract teeth.

Research has shown that there has been a reduction in orthodontic extractions over the last 30 years. Nevertheless, we do not know much  about the factors that may have stimulated this change.  This  team of investigators based in the UK and Ireland did this study to investigate the following.

“Have the members of the British Orthodontic Society (BOS) made any changes in their referrals for orthodontic extractions”?

“If this has happened, why”?

Extraction of premolars for orthodontic reasons on the decline? A cross-sectional survey of BOS members

Fleming et al.  Journal of Orthodontics: https://doi.org/10.1080/14653125.2018.1517470

This is an open access paper, which is great.

What did they do?

They did a simple web based survey of all the members of the BOS. In the survey, they asked if the respondents had changed the proportion of patients they had treated with extractions over the last 5-10 years.

If they reported that they had changed. They then asked them relevant questions on the potential reasons for this change. For example, did they use alternative methods of gaining space, had they become concerned about facial and smile aesthetics etc?

They analysed the data by using simple descriptives and a regression analysis to evaluate any factors that they felt influenced their decisions.

What did they find?

They got 208 responses from a total of 1280 members. This was a response rate of only 16%

Overall, 96% of the respondents stated that they felt that they had reduced the number of extractions they prescribed.  Interestingly, 30% felt that their crowding threshold for extractions had reduced by 2mm.

When they looked at the possible factors that influenced the perceived reduction. They found that these included concerns about facial and smile aesthetics and increased use of inter proximal reduction.  Other reasons were increased use of expansion and proclination of lower incisors.

Their overall conclusion was’

“There is a tendency to reduce orthodontic extractions and an increases use of IPR”.

What did I think?

I thought that this was an interesting, yet small, survey.  While the results provide us with some information, we need to consider that there are two issues with this study.

Firstly, the response rate was low. However, the authors pointed out that they had no real reason to think that the responders were different from the non-responders. While I tend to agree, I would be more confident in their findings if they had reported any information on the responders and non-responders.

Secondly, they collected information on the perceptions of the orthodontists.  This was not the same as actually recording the extractions that they prescribed. As a result, the perceptions could have been influenced by taking part in the survey and the respondents giving answers that they hoped the investigators would like to hear. We all like to appear to be “cutting edge” and reflect what we consider to be a useful trend in practice.

When I consider these factors, I still feel that the survey does provide us with useful information and a further study is required to measure current practice by recording extraction decisions.

I have given this paper some thought because it seems to reflect a change in practice that has occurred in the absence of evidence on any harmful effects of extractions. To my knowledge there has been no well done research into any harms from extractions in the last 15 years.  So why does our practice appear to be changing?

What do I do about extractions?

If I look at my own personal experience, I feel that I have been prescribing less extractions.  I certainly, have no hesitation in recommending extractions when there is severe crowding. However, when crowding is mild I have been more willing to align the arches and reassess the aesthetics and the degree of incisor flaring etc. This has usually resulted in treating non-extraction. I, also, do most of my Class II treatment using functional appliances without extractions.

I think that I have followed this approach because I do not like recommending a rather traumatic treatment to my patients unless I am completely certain that this is the best treatment. Furthermore, we all know that space closure is tricky and it is easier to treat non-extraction and I like to keep my treatment straightforward.  I cannot help feeling that this the most likely reason for my change.

I am sure that this could lead to a lively discussion on the comment section of this post,


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Have your say!

  1. Hi Kevin,
    If the survey was sent to all BOS members, then this is surely not representative of UK orthodontists, as per your title? I am open to correction but I was of the understanding that the BOS is not a specialist orthodontic society, but that rather the bulk of its members are not specialist trained but are GDPs who have an interest in orthodontics?
    Important to clarify this I feel, especially if the results of this study are to be compared with similar studies carried out in other parts of the world that may target orthodontists specifically.
    Did this study compare the responses of GDPs vs specialists, or did it treat the entire sample as a single group?

    • In response to Calvin Case, he is incorrect with his assumption that the bulk of BOS members are non-specialists. The Practioner Group currently has 315 members which make up about 16% of the total Society membership.

      David Manger
      Honorary Treasurer
      British Orthodontic Society

    • I just signed up for your blog today. I was not asked if I am an Orthodontist. How are you getting the statistics?

  2. Great topic
    See Pritchard 1975 JPerio
    The effect of four bicuspid extractions on the Periodontitis for Periodontal issues following 4Bicuspid extractions
    I shall try to send you the paper if I can from my phone
    Colin Richman. 404 784 7272 (C)
    Periodontics and PAOO
    Atlanta Georgia

  3. Not in the UK, but I’ve seen my incidence of extractions actually increase. Crowding, protrusion, curve of Spee leveling, AP correction all need space.

  4. I personally went through the less extraction phase
    several years ago. I now take a cbct to eval the
    alveolar housings among other things. It is not a matter
    of taking out teeth or not. Its a matter of finishing
    cases with teeth well related to the alveolar housings.
    If this is possible without removing teeth then great.
    If not then cold steel and sunshine.

  5. Wisdom teeth.
    If the later prescription for their removal isn’t being accounted for, or if the treating operator is simply ignoring them, then these extraction rates are incorrect. Subsequent third molar removal should be counted in the extraction rates.

  6. I think most of us who have been practicing for several decades have seen a reduction in extractions for the reasons you have mentioned. In addition I also find that I am seeing a lot more milder crowding cases than I did when I completed my specialist training. Thirty years ago patients with very mild crowding rarely attended for orthodontic treatment. Now they do. I also see more adults for orthodontic treatment than I use to. For these adults, more often than for adolescents, we choose simpler compromise non-extraction treatment plans. These are two other reason I, and maybe others, are doing a smaller percentage of our cases with extractions.

  7. Kevin

    To quote Kevin O’Brien: “I also, do most my Class II treatment using functional appliances without extractions.”
    This is something I’ve struggled with forever. Love the philosophy of functional appliances but I still can’t grow mandibles. So Kevin what happens when you start a patient with a functional appliance and you still have measurable OJ at the end. What do you do? Thanks

  8. I think the question needs a better definition. Simply asking if you extract more or less than you did before is too imprecise. This question is loaded with a great deal of potential bias. The question should be – given the specific details of a given malocclusion would the treatment plan be more or less likely to involve extractions than it would have before.

    In a more general reflection of my last 20 years of orthodontic work the following have changed. More minor malocclusions present for treatment, lower incisors are advanced to gain space, there is nothing wrong about finishing a case to a class 2 or 3 molar. Interproximal reduction is used more frequently, functionals are used to both reduce an overjet AND to allow the extraction decision to be deferred until more growth has occurred.

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