Today there are some orthodontists who are attempting to treat all cases without extractions at all cost. [As an side, under the best conditions in a growing child, with good facial balance, and E-space (primary second molars are larger than the succeeding second premolars) it has been reported that 75-80% of orthodontic cases can be resolved non extraction.] The motivation for this approach are many, but the two main ones are: (1) financial [parents and patients like to avoid extractions and view this as conservative treatment], and (2) orthodontic practitioners are not evidence-based, do not know the orthodontic literature. These trends in orthodontics, employing alternatives to extractions of premolars, lack support from refereed literature for many of the nonextraction protocols. Case scenarios and anecdotal reports in non-peer-reviewed journals have wrongly projected a belief that extractions cause unesthetic results such as "dished-in" faces, and "dark-spaces"; at the corners of the mouth, called the buccal corridor.1

In regards to the unfounded remarks about extractions resulting in narrower dental arches when compared with nonextraction therapy. Gianelly2 recently demonstrated that extraction treatment does not result in narrower dental arches than nonextraction treatment, and therefore do not produce "dark-spaces".

In summary the following is a quote from Bowman1 in regards to extraction therapy:

A review of the refereed literature provides little support for the view that premolar extraction has a routinely negative impact on facial esthetics and the functional health of the muscles and joints . . . If one believes that the elimination of extraction treatment is a goal more important than that of addressing the patient's chief complaints concerning protrusion, and if one is unconcerned with the possibility of pushing roots through cortical plates or of poor long-term stability, one can elect to treat all patients without using extraction. However, those who believe in avoiding extraction at all costs should give thought to the possibility that their only ethical option in many patients with crowding and protrusion would be either to refer or to render no treatment at all.

Additionally, Bowman cites Johnston3 who said, “The take home message here is not that nonextraction is bad or that extraction is universally good, but that extraction is a really good treatment in the kinds of faces that appear to need extractions (i.e., [those with] crowding and protrusion)."

REFERENCES:

(1) Bowman SJ. More than lip service: Facial esthetics in orthodontics. J Am Dent Assoc 1999;130:1173-1181.

(2) Gianelly A. Arch width after extraction and nonextraction treatment. Am J Orthod Dentofacial Orthop 2003;123:25-8.

(3) Johnston LE Jr. A long-term comparison of extraction and nonextraction Class II therapy. Presented at: 96th Annual Session of the American Association of Orthodontists; May 11, 1992; St. Louis.