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J Pharm Bioallied Sci. 2021 Jun; 13(Suppl 1): S2–S5. PMCID: PMC8375952
Published online 2021 Jun 5. doi: 10.4103/jpbs.JPBS_549_20 PMID: 34447032

Extraction or Nonextraction in Orthodontic Cases: A Review

Sagar Mapare, Ram Mundada, Arjun Karra, Shivam Agrawal, Sushil Bhagwan Mahajan, and Ashutosh Tadawalkar

Abstract

Orthodontic treatment helps bring teeth in alignment. There is always debate whether tooth should be ex‐
tracted or not for treating crowding. The present article highlights various advantages and disadvantages of
extraction.

Keywords: Crowding, extraction, premolar

Introduction

Orthodontic treatment helps bring teeth in alignment. There are numerous conditions which require or‐
thodontic treatment. These are spacing, crowding, tipping, transportation, increased overjet, overbite, etc.,
The management of orthodontic cases has been performed since ages. Crowding is the condition when
there is minimum space for teeth to be in alignment; hence, teeth are crowded.[1] The management of such
condition can be with extraction of few teeth or nonextraction with movement of teeth. In the 1960s, the
therapeutic extraction became common with an aim to treat crowding. Till the 1990s, the trend declined;
then again, there was a rise in the extraction cases.[2]

History

Deciduous teeth have been extracted since many years to create space for permanent teeth to erupt in right
place. However, few dentists started extracting permanent teeth also as there was requirement of more
space. Hunter[3] in 1771 was in disagreement and gave the clarification that with the extraction of perma‐
nent teeth; there is a chance of growth inhibition.

h
In the 18th century, extraction of maxillary first premolars was considered to be the best treatment option
in cases of class II, division I malocclusion. Delabarre suggested that first, one should plan whether extrac‐
tion is really helpful or not. Davenport[4] in his speech in New York suggested loss of teeth as loss of an
important organ. Angle,[5] the father of modern orthodontics, was in favor of extraction of teeth for bring‐
ing out better results. Multiple case series and research data are available in his book entitled, “Treatment
of Malocclusion of the Teeth and Fractures of the Maxillae-Angle System.”

Rousseau, a philosopher, was again in opposition who declined the concept of extraction. He pointed out
that an ideal occlusion may not necessarily be accomplished by extraction. Later on, Julius Wolff intro‐
duced the Wolff's law of bone in which he revealed that stress can lead to alteration of trabeculae. He pos‐
tulated that when force is applied to teeth, bony trabeculae show changes in response to stress produced by
forces.

Angle suggested that orthodontic forces may lead to growth of bone if teeth were placed in a proper occlu‐
sion. He mentioned his edgewise appliance as a “bone growing appliance.” He proposed the idea that there
is an interrelation of dentition with facial profile. There is an alteration in facial esthetics with the move‐
ment of teeth, and esthetics is the best when all teeth are aligned in occlusion. He tried to preserve all natu‐
ral teeth of patients by expanding the dental arches.

Controversy

Facial profile

One of the factors which plays an important role in deciding whether extraction should be performed or
not, is the facial profile. Those who oppose extraction suggested that there is dish in of the face with ex‐
traction whereas those in favor thought that there will be fullness of facial profile.[6] A study of Rushing et
al.[7] on effects of orthodontic extraction on facial profile suggested that most of the dental surgeons and
orthodontists cannot judge whether extraction has been performed or not without seeing the patient clini‐
cally. This was supported by the work of Stephens et al. and Erdinc et al.[8]

Solem et al.[9] conducted a study (2013) in which they assessed the effect of bimaxillary protrusion on
soft and hard tissues of the face. The authors found that there was subsequently retraction of upper lip post
extraction. They suggested that extraction may be helpful in patients having fuller profiles and hence there
are less chances of “dish-in” of the face; therefore, extraction is the best option in these patients. There is a
need to study the case extensively as facial profile may show alteration due to overretraction of the maxil‐
lary anterior segment.

Konstantonis et al.[10] evaluated the effect of extraction on the soft tissue profile of patients. This was a
meta-analysis performed on 9 databases. They assessed 24 studies which comprised 1456 patients and
found that there was a mean difference of 1.96 mm between upper and lower lips. Extraction of teeth re‐
sulted in increased lower lip retraction. They studied 1149 patients in 21 studies and found a mean differ‐
ence of 1.26 mm between upper and lower lips and suggested an association of extraction with upper lip
retraction. Twenty-one studies comprised 109 patients which revealed association of extraction with na‐
solabial angle with a mean difference of 4.21°. Six studies were on profile convexity on 408 patients, in
which the mean difference of 1.24° was found. Three studies showed a standardized mean difference of
0.41 in 249 patients. They suggested that patient profile may be affected with extraction; hence, no specific
profile outcome may be proposed.

Buccal Corridors

It is a belief of few researchers that extraction of maxillary premolars bring narrowing of the maxilla, lead‐
ing to broader buccal corridors. Ioi et al.[11] in their study assessed the effect of smile esthetic on buccal
corridor. In this study, a patient picture showing the maxillary right first molar to left first molar (16–26)
was displayed; buccal corridors were modified digitally in 5% increments, from 0% to 25% buccal corridor
compared with the inner commissural width and distributed among 32 Japanese orthodontists and 55
Japanese dental students to rate the six smiles. The authors found no significant difference in deciding the
effects of buccal corridors on the smile attractiveness between both gender raters for both groups of dental
surgeons. Both groups of dentists showed significant differences in the median esthetic scores. The median
esthetic score decreased to become clinically significant from 10% to 25% buccal corridor for both groups.
The result of this study was supported by the results obtained by Meyer et al.[12] who also suggested that
broader buccal corridors may be attractive and extraction of maxillary premolar does not necessarily lead
to narrow maxillary ridges.

Temporomandibular Joint Disorders

It is usually misconcept that extraction of teeth in orthodontic patients leads to temporomandibular joint
disorders (TMDs). Hardly, there is any correlation of TMDs and orthodontic tooth extractions.[13]
Gianelly et al.[14] in their study recruited 111 patients, out of this 79 patients underwent orthodontic treat‐
ment without extraction, 32 underwent extraction, 27 with 1 or more premolar extraction, and 5 with ante‐
rior tooth extraction. In all patients, assessment of condylar position was done before and after treatment.
The results revealed nonsignificant difference in pretreatment and posttreatment condylar positions in all
cases. The authors suggested that there is no movement of condyle during orthodontic treatment.

Stability Loss

Bowman et al.[15] suggested that nonextraction of teeth in every patient may not always be helpful since
there is variation in oral conditions in reference to positioning, tipping, and crowding in different patients.
Thus, extraction may be planned in some cases to obtain better results. Erdinc et al.[16] in their study re‐
vealed that the extraction of premolars for orthodontic treatment to improve crowding may not augment
stability.

Risk of Impaction

Saysel et al.[17] suggested that with the extraction of premolars in orthodontic patients, there is more
space for the third molar to erupt, hence the chances of impaction decreases. Turkuz et al.[18] found that
approximately 81% of cases of third molar impaction in those patients who did not go for extraction of pre‐
molars, whereas only 63% of third molar impaction cases were found in extraction cases. Cassetta et al.
[19] conducted a study, which comprised 40 patients with mandibular second molar impactions and 200
patients without second molar impactions. The study group exhibited significant presence of crowding, a
smaller distance between the anterior margin of mandibular ramus and mandibular first molar, and higher
angle of mandibular second molar inclination.

Expansion

It is suggested that expansion of maxillary arch may be useful in resolving crowding. Rapid maxillary ex‐
pansion (RME) can be fruitful in borderline crowding (3–6 mm) in the mandible in patients with narrow
transpalatal widths. It is evident that there is reciprocal mandibular expansion in reference to RME.[20]

Housley et al.[21] in their study found that 8% of patients had significant intercanine widths for more than
6 years who underwent mandibular expansion. Risk such as regression of labial or buccal cortical plate is
seen in maxillary expansion cases.

Preservation of Leeway Space

It is evident that leeway space may be utilized for the treatment of mild-to-moderate crowding in patients
with Class I and II malocclusion. Sonis et al.[22] found that the use of a lingual arch in the mixed dentition
may be used for resolving mild-to-moderate crowding. However, in moderate-to-severe crowding, extrac‐
tion of premolars is the best option. According to the contemporary extraction guidelines, extraction is
rarely indicated in <4 mm of arch length discrepancy, posterior extraction may be required with 5–9 mm
of arch length discrepancy and with >10 mm arch length discrepancy extraction is always required.[23]

Air-rotor Stripping

It is suggested that approximately 6–8 mm of the space can be achieved to resolve protrusion, crowding, or
a combination of both.[24]

Conclusion

The authors suggested that extraction and nonextraction of teeth in the treatment of crowding is solely an
orthodontist decision. The consideration of advantages and disadvantages of extraction is essential before
planning treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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