The extraction of teeth: Part 1

diagnostic and treatment considerations

Laurance Jerrold, Cindy Chay, and Mayte Accornero

Non extraction therapy is NOT a treatment goal. It is merely a means of effec-

tuating a treatment goal. The same mindset applies to extraction therapy
it is a means to an end. The first diagnostic consideration in contemporary
orthodontic therapy should be to decide where one wants to place the teeth.
This answer is based on a host of considerations that are driven by patient
preferences, professional experience and expertise, and evidence based data
relating to the clinical issues at hand. Treatment considerations follow and
they too are based on a number of factors such as anatomical, physiological,
and functional limitations, patient cooperation, and biomechanical expertise
to name a few. In the end, the decision to extract teeth or not should support
the five goals that provide support for the bases behind professional ortho-
dontic intervention: 1) the creation of a harmonious balance in the alignment
of the dentition, 2) maximizing occlusal contacts, 3) enhancing dentofacial
esthetics, 4) creating a functional occlusion, and 5) achieving a relatively
physiologic stable result. (Semin Orthod 2019; 25:309–317) © 2019 Elsevier
Inc. All rights reserved.

T here has been a pendulum swing in ortho-

dontics concerning extraction therapy for
approximately the last 100 years even though the
extraction of teeth to address space require-
ments was first reported in 1771.1 Currently,
non-extraction therapy is more in vogue; how-
ever, this approach should not be viewed as a
treatment goal. The decision to extract or not
extract teeth should be viewed as nothing more
than a method of achieving whatever one’s diag-
nostic and therapeutic goals are for treating a
particular patient. The following are a number
of generally accepted reasons for extracting per-
manent teeth.2 They are:
1. Resolution of crowding.
2. Resolution of inter-arch tooth size discrepan-
cies.
Division of Orthodontics, NYU Langone Hospitals, Brooklyn,
NY, United States; Private Practice of Orthodontics and Pediatric
Dentistry, Nanuet, NY, United States; Division of Orthodontics,
NYU Langone Hospitals, Brooklyn, NY, United States.
Corresponding author: Laurance Jerrold, DDS, JD, 96 Aspen
Drive East, Wodbury, NY, 11797 United States. E-mail:
drlarryjerrold@gmail.com
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2019.10.001
3. Reduction of excessive proclination of the
anterior teeth.
4. Reduction in lip procumbency (profile reduc-
tion).
5. Correction of the midline.
6. Camouflage skeletal mal-relationships.
7. Adjunctive decompensation of the dentition
prior to orthognathic surgery.
8. Interdisciplinary considerations (perio-endo-
restorative/prosthetic).
9. Establish a more ideal intercuspation or inter-
incisal relationship of teeth.
These reasons underpin a practitioner’s profes-
sional obligation when attempting to meet one or
more of the five goals that comprise the basis for
providing orthodontic treatment; those being creat-
ing a harmonious balance among tooth alignment,
maximizing occlusal contacts, enhancing dentofa-
cial esthetics, creating a functional occlusion, and
achieving a relatively stable final result.3
Resolution of crowding diagnostic and
treatment considerations
When considering whether or not to extract
teeth, one question that needs to be asked is how
will the patient’s hard tissue support be affected?

Seminars in Orthodontics, Vol 25, No 4, 2019: pp 309 317 309

310 Jerrold et al
For example, a hard tissue consideration might
come into play when extracting either a partially
erupted tooth, a buccally displaced ectopically
erupted tooth, a tooth that is ankylosed, or exces-
sive expansion of dental units anteriorly and/or
laterally. Each of these clinical situations carries
the consideration that the supporting alveolar
bone may be compromised as a result of the pro-
cedure embarked upon. In many cases there may
not be another viable treatment alternative but
in those cases where choosing a different extrac-
tion pattern, changing the timing of certain
aspects of treatment, or deciding not to position
teeth off their supporting alveolar process is pos-
sible, those alternatives should be considered.
The same considerations apply to the support-
ing soft tissues. Both extraction and non-extrac-
tion therapy have the potential to affect the
dentoalveolar soft tissue support. Soft tissue peri-
odontal support, particularly in those patients
whose biotype is thin or weak, may be acutely sus-
ceptible to iatrogenic compromise if taxed
beyond their ability to positively withstand or
respond to the treatment rendered.
Ultimately, the following considerations must
be evaluated; (1) the esthetics associated with plac-
ing proclined versus upright incisors in the
esthetic zone; (2) whether teeth have been placed
in such a position as to jeopardize their long-term
potential for relative stability due to an imbalance
in the dynamic equilibrium of that patient; (3)
whether or not the final positions of the teeth are
such that their interdental relationships will
adversely affect the functionality of the occlusal
scheme; and (3) whether or not the positions of
the teeth will contribute to periodontal compro-
mise in any way. All of these “potential negative
sequalae” must be pitted against the “value” of
maintaining a full complement of teeth along with
any “soft costs” related to extraction therapy such
as temporal and financial considerations, or the
risks and discomforts associated with exodontia.
Another consideration concerns the patient’s
ability to cooperate with the treatment plan cho-
sen. Today we have the ability to employ both
intra and inter arch mechanics that can either
necessitate the patient’s cooperation; or, in the
alternative, be independent of patient participa-
tion save for showing up for their appointments
and maintaining minimally acceptable oral
hygiene practices. Once one is engaged in extrac-
tion therapy the question always exists as to
whether the extraction of teeth in and of itself
has provided a benefit to the patient; or, whether
the practitioner, because teeth were extracted,
has placed the patient in a worse position than
before teeth were extracted? If cooperation will
be needed, and if after consultation with the
patient/parent it can be established that mecha-
notherpeutic cooperation or adequate home
care will not be acceptable, one should question
the decision to remove teeth; as it is somewhat
more problematic to discontinue treatment or
terminated the doctor patient relationship
should the clinical situation dictate such action.
Another question to ask is whether or not any
existing dental units have a poor or guarded prog-
nosis? Any tooth is amenable for extraction under
the appropriate set of clinical circumstances. This
point will be discussed later. However, the consid-
eration that needs to be addressed at this point in
time is whether or not it is prudent to extract a
tooth that has a poor prognosis or is potentially
compromised as opposed to one that comports
with more traditional extractions schemes. For
example, an endodontically retreated second pre-
molar with a continuously non-resolving periapi-
cal lesion should be considered for extraction as
opposed to the desired first premolar. The ques-
tion then becomes whether or not the practi-
tioner has the clinical expertise to engage in an
atypical or asymmetric extraction pattern as
opposed to a typical symmetrical extraction pat-
tern and if not, whether to change to an all sec-
ond premolar extraction pattern? The potential
for implant site development also needs to be con-
sidered when faced with a dental unit that has a
poor or guarded prognosis as keeping the site via-
ble for a future implant may once again necessi-
tate changing the extraction scheme to one that
was not originally considered.
Arch development is a somewhat controversial
concept in clinical orthodontics. It is generally
accepted that expanding the mandibular interca-
nine width, without concomitant long-term fixed
retention, generally carries a guarded prognosis
regarding stability and may also result in periodon-
tal compromise. In addition, the same concerns
attach to excessively flaring the lower anterior
teeth.4 6 Maxillary expansion in order to facilitate
lateral uprighting of the mandibular dentition
may provide adequate space to relieve mandibular
crowding; however, it too may result in some
degree of periodontal compromise and instability
 The extraction of teeth: Part 1 diagnostic and treatment considerations
as well as reducing the functionality of the Curve
of Wilson.7,8 Finally, it must be remembered that
lower molar uprighting may be accomplished
either posteriorly or laterally. If uprighting posteri-
orly, the following questions must be addressed.
First, is there sufficient freeway space? Second, will
any resulting clockwise mandibular rotation result
in accentuating the height of the lower facial
third? Next, will an open bite result from the
uprighting? Finally, if uprighting laterally, is there
sufficient transverse maxillary arch width to
accommodate the expansion?
Resolving inter-arch discrepancies -
Diagnostic and treatment considerations
Changing the size or shape of individual dental
units is one useful method of resolving both inter
and intra arch discrepancies that usually result
from morphological and anatomical deviations
in tooth size and shape. Interproximal reduction
is an often utilized methodology to resolve minor
to moderate amounts of crowding (up to
8 mm).9,10 However, before undertaking any
type of irreversible procedure, such as selective
enamelplasty, practitioners should first address
the clinical considerations associated with such
procedures. When considering reproximation in
either arch, to resolve lower anterior crowding
for example, if there is no inter arch tooth size
discrepancy initially, what will the resulting occlu-
sion be after removing tooth structure in just one
arch? Secondly, if reproximation is performed,
will the health of the patient’s hard or soft tissues
be compromised in any manner? Finally, reproxi-
mation to resolve crowding should generally not
be performed if there is a possibility of requiring
the extraction of dental units later on in treat-
ment to address space requirements as the
reproximation performed may now have created
an inter and/or intra tooth size arch length dis-
crepancy where none previously existed.
Inter arch mechanics is another means of
addressing inter-arch occlusal discrepancies.
Inter-arch mechanics effect the dentoalveolar
structures in a number of different ways. For
example, assume that the elastic traction extends
from a mandibular first molar in one arch to the
archwire in-between the lateral and the canine in
the opposing arch; as opposed to being directly
attached to the canine in the opposing arch. 4
premolars have been extracted, and, we are
311
utilizing Cl II mechanics. It is well known that
there is both a horizontal as well as a vertical
component associated with Cl II elastic usage.
Therefore, there is an extrusive component to
the lower molar and an extrusive component to
the anterior portion of the upper arch. The
degree of clinical significance of these force com-
ponents depends on the degree of angulation of
the vertical vector and the amount of force being
utilized. In other words, does the elastic run
from the lower first or the lower second molar;
or, is a “short Cl II” running off of the premolar?
As one moves anteriorly, there is a greater extru-
sive effect on the lower “anchor’ tooth. There is
a corresponding vertical component to the ante-
rior portion of the upper arch that has the poten-
tial to cant the occlusal plane inferiorly when
viewed from the posterior to the anterior. Extrac-
tion therapy may have the potential to negate
some of the vertical component in those cases
where the posterior teeth are being brought
anteriorly into the extraction site.11,12
There is also an effect on the maxillary and
mandibular teeth. Depending upon the wire con-
struction relative to the use of, or absence of,
molar stops, the maxillary anterior teeth may ret-
rocline and the mandibular anterior teeth may
procline in response to the horizontal compo-
nent of Class II elastics. The mandibular poste-
rior teeth will have a tendency to move in an
anterior direction undergoing either tipping,
bodily movement, and/or mesial rotation,
depending upon the use of, or lack of various
gabling techniques in the archwire. These result-
ing effects can be accentuated during closure of
premolar extraction spaces.
One must be cognizant of the potential for
periodontal effects secondary to any mandibular
dental proclination that may result from using
inter-arch elastic traction if treatment is under-
taken on a non-extraction basis.13 Premolar
extraction therapy provides the potential to off-
set labialization of the lower anterior teeth
depending upon the intra-arch mechanics used.
Finally, there is the effect on the mandible itself.
Being a movable bone subject to positional
change, the mandible can respond in a number of
ways. Depending upon mandibular anatomy, inter
arch occlusal relationships, musculature, amount
of elastic force used, and the resulting intra oral
force vectors, mandibular postural changes can be
directionally expected; however, the amount of
312
change cannot be accurately predicted.7 These
force vectors can be influenced by the presence or
absence of specific premolar teeth.
In summary, if premolar extraction spaces
have been created, one must be concerned with
the potential overall effects regarding the
patient’s skeletal, hard and/or soft tissues, occlu-
sal relationships, and function. One more con-
cern relates to those patients with fragile TM
joints. Regardless of whether or not premolar
extractions have been performed, should tempo-
romandibular joint symptoms arise it may be wise
to evaluate the use of inter-arch mechanics to
assess whether the joint disturbance might be
related, or not, in some way to their use.14
Molar distalization mechanics using any num-
ber of extraoral or intraoral appliances is another
means of resolving inter-arch discrepancies. The
decision to employ any of these mechanotherpeu-
tic treatment modalities may also influence one’s
decision on whether or not to extract teeth.
Studies by Sfondrini et al., Baek et al., and
Singh et al.15 17 have addressed many of the fol-
lowing considerations regarding the use of maxil-
lary distalization mechanics using a variety of
appliances. Some specific considerations looked
at were, what was the effect on the patient’s skele-
tal, dental, and/or occlusal relationships? If the
molar is successfully distalized, will there be a
reciprocal side effect of opening the vertical
dimension and/or anterior anchorage loss
depending on the mechanotherapy employed?
Will the molars be excessively tipped as opposed
to being moved bodily? Will the occlusal plane
become canted? If successful, will there be an
effect on the esthetic zone relating to the size of
black triangles in the buccal corridors versus any
effect that may be associated with extraction ther-
apy? Will employing these mechanics have a nega-
tive effect on other hard tissues; for example, by
impacting more posteriorly positioned molars?
Will utilizing these mechanics as opposed to
extraction mechanics have a negative effect on
any soft tissues (will they result in palatal irritation,
epuli of the buccal mucosa or cheek, etc.)?
Finally, will the facial balance be negatively
impacted by increasing the lower facial third
resulting from a downward and backward mandib-
ular rotation? If any of these questions are
answered in the affirmative, some consideration
to extraction therapy may be warranted. Sfon-
drini15 summed up the issue beautifully by noting:
Jerrold et al
Conventional molar distalization is not always
indicated for Class II correction. It is contrain-
dicated in open-bite patients and in the pres-
ence of a protrusive profile. In open-bite
patients molar distalization would determine a
clockwise mandibular rotation, thus increasing
the lower face height and worsening the facial
appearance. In the case of protrusive facial pro-
file the anterior anchorage loss, which occurs
during molar distalization, would worsen the
inclination of the front teeth and, conse-
quently, the profile itself. Molar distalization is
recommended for the correction of Class II
malocclusions in deep-bite patients and in the
presence of a concave or normal facial profile.
In borderline patients, the choice between
whether to extract teeth or distalize molars
must be made also taking into account the pos-
sibility of a longer treatment time of a non-
extraction approach.
Lastly, as previously discussed, can the patient
adequately comply with any necessary coopera-
tion needed if non-compliance mechanics are
not employed? If not than considering extraction
therapy may be a viable alternative.15
Reduction of excessive proclination of the
anterior teeth - Diagnostic and treatment
considerations
Flared teeth, particularly in children and more
specifically in patients exhibiting an overjet of
greater than 5 6 mm, have a higher potential for
injury resulting from trauma.18 20 One reason is
that excessively flared anterior teeth are often out-
side of the soft tissue envelope of protection
offered by the perioral musculature. While molar
distalization offers one way to provide space into
which anterior teeth can be retracted, the extrac-
tion of dental units is also a viable alternative.
Bimaxillary dentoalveolar protrusions often result
in lip incompetency that may increase exposure
of the anterior gingiva to the environment result-
ing in inflammatory hyperplasia.21,22 Dentoalveo-
lar protrusions can also result in a gummy smile
that may compromise the esthetic zone. The
extraction of dental units, particularly premolars,
is a viable means of providing the necessary space
to retract the anterior dentition, thus placing it
within the confines of the perioral musculature.
Finally, if a non-extraction approach will result in
 The extraction of teeth: Part 1 diagnostic and treatment considerations
excessive labialization of the anterior teeth off
their supporting base to the extent that periodon-
tal compromise may result, thought should be
given to extraction therapy.
Reduction in lip procumbency (profile
reduction) diagnostic and treatment
considerations
Bimaxillary dentoalveolar procumbency is not, in
and of itself, a pathologic condition. Depending
upon the skeletal makeup and ethnicity of the
patient, some degree of perioral fullness in the
“muzzle” area may be considered normal. In
other cases, it should be viewed as merely a varia-
tion of normal unless the associated lip incompe-
tency is causing the patient a potential for
traumatic injury, esthetic, or functional con-
cerns. Lip procumbency may also be the result of
the patient’s dynamic equilibrium at work, plac-
ing the dentition in a position based on the bal-
ancing influences of the patient’s occlusion,
muscularity and function.30
Orthodontically, the best means of addressing
this concern is through the extraction of teeth
allowing for the anterior dentition to be moved pos-
teriorly with a concomitant change in the soft tissue
drape.23 26 Unfortunately, this soft tissue drape
change does not manifest itself with any degree of
predictability as the lips do not move in any specific
ratio to the movement of the underlying dentition
because of the varying thickness, tonicity, muscular-
ity, anatomy, and function of perioral tissues found
among patients.27 29 If considering retraction into
the extraction spaces, one should endeavor to use
as treatment goals any of the established norms for
the patient’s particular ethnicity, assuming the
patient has not expressed a specific desired goal.
Obviously, the closer the extraction site is to the
area of deformity or desired change, the greater
the potential for that change to occur.
If profile reduction is embarked upon by utiliz-
ing extraction spaces, one first has to consider the
anchorage needs to effectuate the treatment
goals; and second, whether one is relying on any
required levels of patient cooperation in order for
the proposed mechanotherapy to result in the
desired change. One must also ascertain whether
the positional anatomy of the dentition and perio-
ral musculature can support the proposed treat-
ment mechanics and anticipated placement of
the anterior dentition. If there are concerns about
313
whether the bony and soft tissue support will be
adequate for the proposed tooth movement, one
may choose to consider a different extraction pat-
tern and/or modification of the treatment goals.
Correction of the midline diagnostic
and treatment considerations
Jerrold and Lowenstein31 note that facial asymme-
try that is amenable to orthodontic correction is
dependent on all three of the patient’s midlines
(facial, maxillary, and mandibular) being relatively
symmetrical. If the facial midline is asymmetric, e.g.
soft tissue pogonion is not coincident with exten-
sion of the line extending from soft tissue nasion
and bisecting the philtrum, the etiology of the asym-
metry needs to be addressed to determine if the
lower third (mandibular) asymmetry is skeletal or
functional. All functional shifts must either be cor-
rected or accounted for before assessing the cor-
rectness of the maxillary and mandibular midlines.
Assuming the face is symmetrical hence the
“facial midline” is on, one should next address
the maxillary midline. The first diagnostic chal-
lenge is ascertaining the degree of deviation and
whether this discrepancy can be adequately
addressed utilizing a non-extraction approach. If
the discrepancy is too great, or other special
needs exist in any particular quadrant of the
arch, then extraction therapy should be consid-
ered. Extraction therapy could employ, depend-
ing upon the clinical specifics of the case,
symmetrical extractions in one or both arches,
an asymmetrical extraction pattern in one or
both arches, or a unilateral extraction pattern in
one or both arches.
Once the maxillary midline has been assessed
and “pre-treated” by performing an orthodontic
visual treatment analysis, the mandibular dental
midline can then be assessed with the goal of hav-
ing it coincide with the facial and maxillary mid-
lines. The same thought process applicable to
the maxilla applies to the mandible regarding
the possibility of non-extraction therapy, save for
the fact that the mandibular posterior teeth are
not as amenable to distaliztion mechanotherapy
as their maxillary counterparts. If posterior den-
tal distalization is not viable, then the appropri-
ate extraction pattern should be considered. It
goes without saying that extracting a lower ante-
rior tooth usually results in a lower dental mid-
line asymmetry unless the lower anterior tooth is
314 Jerrold et al
part of a greater asymmetrical or atypical single
or double arch extraction pattern
Diagnostics aside, Nanda and Margolis32 dis-
cuss specific treatment considerations relative to
midline correction. If the midlines are not coor-
dinated secondary to a mandibular functional
shift one must ensure that archform coordina-
tion will exist to accommodate the dentition
once the shift has been corrected. In addition,
one must also ensure that once the shift has
been corrected, the individual teeth have room
in the arch to be able to function appropriately
with their antagonists and this may require the
use of an atypical or asymmetrical extraction pat-
tern. Space may be able to be obtained utilizing
interproximal reduction, however it is critical to
note that in cases exhibiting functional shifts in
association with dental midline asymmetries it is
not unusual to require more space in a specific
quadrant thus making it outside of the reach of
reproximation to generate the needed space.
If engaging in a non-extraction approach to
midline coordination, the following general caveats
are first, to make sure the patient can cooperate
with whatever their part in the mechanotherapeu-
tic approach will be; second, if utilizing reproxima-
tion, can the hard and soft tissues tolerate the
procedure; and third, if camouflaging the denti-
tion to account for an underlying skeletal compo-
nent, will the proposed position of the teeth
compromise their supporting hard or soft tissue
structures, the profile, the esthetic zone, or the
proximal, occlusal, or functional demands regard-
ing the choice of tooth to be extracted.
Skeletal midline asymmetries have been inten-
tionally omitted from discussion.
Camouflage skeletal malrelationships by
orthodontics alone diagnostic and
treatment considerations
Non-extraction camouflage treatment should
ideally be accomplished within existing anatomic
limitations without posing a threat to hard or soft
tissue integrity (root resorption, root perfora-
tions, dehiscences, etc.) given the treatment
plan. If there is the potential for any hard or soft
tissue compromise, one should consider whether
extraction therapy has the potential to minimize
or negate those concerns?
If any form of camouflage therapy has the
potential to create a reasonably functional
occlusion, one must then decide whether the
dental and facial esthetic result will be acceptable
irrespective of whether a non-extraction or
extraction approach is undertaken?
In other words, the following reciprocal ques-
tion must be asked. If camouflage therapy is
undertaken for correction of a dysfunctional
occlusion, how will orthodontic intervention
affect the soft tissue drape; must then be followed
by, if camouflage is undertaken for correction of
the soft tissue drape, how will orthodontic inter-
vention affect the resulting occlusion and func-
tion? The answers to both of these questions
should help the practitioner decide on which
approach, non-extraction or extraction, may
have an advantage over the other.
Camouflage therapy on growing adolescents
presents significant challenges.33,34 First and fore-
most is understanding that the camouflage treat-
ment approach may not work out. If one sees that
the case is not treating out as expected, the follow-
ing questions need to be addressed. Can the cam-
ouflage approach be discontinued mid-treatment
without further compromise of the patient’s hard
and/or soft issues? If it was attempted on a non-
extraction basis, will extraction therapy address
those concerns? If the camouflage approach uti-
lized extractions, one needs to consider whether
or not the camouflage will be able to be reversed
if later on the patient decides he now wishes to
undergo an orthognathic surgical correction?
Finally, three absolute caveats must be
addressed. First, if embarking on camouflage ther-
apy, regardless of whether a non-extraction or
extraction approach was undertaken, is the patient
capable of participating in any necessary coopera-
tion requirements? Secondly, one should never
embark in camouflage therapy if there is any
chance that doing so will preclude the ability to
receive more ideal treatment in the future and the
patient accepts that limitation? Lastly, is the patient
aware that what is being rendered is definitively
compromised treatment?
Remove dental compensations prior to
orthognathic surgery diagnostic and
treatment considerations
Patients who present with maxillo-mandibular
skeletal discrepancies may exhibit underlying
dental compensations related to the discrepancy
in all three planes of space thus necessitating
 The extraction of teeth: Part 1 diagnostic and treatment considerations
pre-surgical orthodontic treatment consisting of
arch alignment, arch coordination and dental
decompensation.35 When dental compensatory
discrepancies are mild, decompensation can usu-
ally occur on a non-extraction basis. However,
when the discrepancy is severe or if dental shift-
ing within an arch has created a “malocclusion
within a malocclusion”, decompensation is often
best treated utilizing extraction therapy; the pat-
tern to be dictated according to the clinical find-
ings of the case.36 The extraction pattern chosen
should provide for the most expeditious place-
ment of the dental units within each quadrant
that will render the best inter arch occlusion
post-surgery. Prior to embarking on pre-surgical
decompensatory orthodontic therapy, one needs
to determine what effect, if any, it will have on
the health and/or longevity of the patient’s den-
tition, hard and soft tissue supporting structures
and/or the extraoral soft tissue drape.37 39
Particularly when contemplating extraction
therapy to address decompensating the dentition,
one should determine how much decompensation
should be done prior to surgery and how much
should be done after the surgery has been com-
pleted.40 In addition, it is important to be cogni-
zant of the fact that regardless of the extraction
pattern chosen, the anchorage requirements in
each quadrant will not be the same as in a non-sur-
gical extraction case. This is because each quadrant
within each arch must be treated independently
regarding dental unit positioning as the surgery
will correct the inter arch occlusion.
Another factor in choosing the best extraction
pattern is whether interdisciplinary restorative or
prosthetic treatment is contemplated post-surgery.
In that case, individual teeth must be positioned to
accommodate the restorative end result with the
“to be” occlusal scheme being factored into the
surgical correction. Finally, decompensation is not
a “zero sum game” and some dental unit compen-
sation may have to remain in any given case.
Interdisciplinary considerations (perio-
endo-prostho-etc.) diagnostic and
treatment considerations
Interdisciplinary therapy carries some additional
considerations when deciding whether or not to
extract teeth in a given case. One of the more
common conundrums is the situation where there
is posterior spacing secondary to tooth loss and
315
anterior crowding with excessive anterior procli-
nation and associated lip incompetency. On one
hand one would like to close the posterior spacing
by retracting anterior teeth; however, that may not
resolve both the crowding and the proclination as
the available space may be too distant from the
site of the deformity and there may be insufficient
anchorage to achieve the treatment goals. Alter-
natively, one may want to consider extracting
teeth that are in closer proximity to where the
space is needed while relying on a restorative or
prosthetic solution posteriorly. In other words, in
some cases, orthodontic treatment is adjunctive to
any restorative or prosthetic needs; while in other
cases, the restorative or prosthetic needs can be
adjunctive to the orthodontic requirements; and
finally, there are cases where the various interdis-
ciplinary needs are independent and do not
directly interact with each other.41 43
Other interdisciplinary considerations are the
effects that the decision to extract or not extract
will have on the hard and soft tissue supporting
structures. Will you be creating the need for
interdisciplinary treatment where none presently
exists? Will orthodontic therapy, with or without
tooth removal, address the interdisciplinary
problem or will it still remain? Will the orthodon-
tic treatment address one interdisciplinary prob-
lem but simultaneously create a different one?
Who will be the “captain of the ship”, deciding
on the course of treatment and making the ulti-
mate recommendations to the patient? Is the
patient able to commit to the required levels of
cooperation with the treatment plan regarding
home care, mechanotherapy, time commitment,
financial commitment, etc?
Establish a more ideal intercuspation of
teeth diagnostic and treatment
considerations
One of the primary considerations regarding the
decision to extract or not extract teeth relates to
the prognosis for achieving an esthetic, stable,
and functional occlusion. Other factors that need
to be considered are, how much of the Curves of
Spee and Wilson should be corrected, the degree
of correction needed for uprighting lower ante-
rior teeth, evaluating the effective use of both the
leeway and the freeway space, the potential for
impacting third molars, and the decision to keep
specific teeth in typical versus atypical positions
316 Jerrold et al
given the extraction decision, etc? In addition,
one needs to assess whether there a CR/CO dis-
crepancy of a magnitude that it will influence the
decision to extract or not? As was stated earlier,
one needs to know if there a functional shift that,
if detected, would affect which teeth would be the
best candidates for extraction?
One also needs to establish a goal for the occlu-
sal scheme you intend to create.44 Often a diag-
nostic set-up helps to confirm not only the
treatment plan but the extraction pattern that
best addresses the intra and inter occlusal needs
of each case. Prior to confirming a diagnosis and
treatment plan one needs to confirm that the clin-
ical picture is as it appears to be in that all cross-
bites, functional shifts, CR/CO discrepancies, etc.
have been duly considered. If necessary, a thera-
peutic diagnosis and trial sequence of treatment
should be undertaken with a specific time frame
for re-evaluation. Finally, some degree of compro-
mise may be necessary which does not in and of
itself create clinically relevant problems.
References
1. Sangamesh GF, Deepti T, Siddarth R, et al. Mandibular
incisor extraction: a case report. Int J Sci Study. 2013;1
(3):159.
2. Contemporary Orthodontics 5 Ed.Proffit WR, Fields Jr.
HW, Sarver DM. Chapter 7: Orthodontic Treatment Planning:
From Problem List to Treatment Plan. St. Louis, MO: Elsev-
ier/Mosby; 2013.
3. Needham R, Waring DT, Malik OH, et al. Invisalign treat-
ment of class iii malocclusion with lower incisor extrac-
tion. J Clin Orthod. 2015;XLIX(7):429.
4. Renkema AM, Fudalei PS, Renkema AA, et al. Gingival
labial recessions in orthodontically treated and untreated
individuals: a case Control Study. J Clin Periodontol.
2013;40(6):631.
5. Slutzkey S, Levin L. Gingival recession in young adults:
Occurrence, severity, and relationship to past orthodontic
treatment and oral piercing. Am J Orthod Dentofac Orthop.
2008;134(5):652.
6. Artun J, Krogstad O. Periodontal status of mandibular
incisors following excessive proclination. A study in adults
with surgically treated mandibular prognathism. Am J
Orthod Dentofac Orthop. 1978;91(3):225.
7. Gianelly A. Rapid palatal expansion in the absence of cross-
bites: Added value? Am J Orthod Dentofac Orthop. 2003;124
(4):362.
8. Housley JA, Nanda RS, Currier, GF, et al. Stability of
transverse dimension in the mandibular arch. Am J Orthod
Dentofac Orthop. 2003;124(3):288.
9. Frindel C. Clear thinking about interproximal stripping.
J Dentofac Anom Orthod. 2010;13(2):187.
10. Sheridan JJ, Chudasama D. Guidelines for contemporary
air rotor stripping. J Clin Orthod. 2007;41(6):315.
11. Xu T-U, Lin JX, Huang JF, et al. Effect of the vertical force
component of class ii elastis on the anterior intrusive force
of the maxillary archwire. Eur J Orthod. 1992;14(4):280.
12. Ellen EK, Schneider BJ, Selke T, et al. A comparative
study of anchorage in bioprogressive versus standard
edgewise treatment in class II correction with intermaxil-
lary elastic force. Am J Orthod Dentofac Orthop. 1998;114
(4):430.
13. Yared KFG, Zenobio EG, Pacheco W, et al. Periodontal
status of mandibular central incisors after orthodontic
proclination in adults. Am J Orthod Dentofac Orthop.
2006;130(1):6.e1.
14. Proffit WR, White RP. Surgical Orthodontic Treatment. St.
Louis: Mosby Yearbook; 1991.
15. Sfondrini MF, Cacciafesta V, Sfondrini G, et al. Upper
molar distalization: a critical analysis. Orthod Craniofacial
Res. 2002;5(2):114.
16. Baek ES, Hwang S, Kim K-H, et al. Total intrusion and dis-
talization of the maxillary arch to improve smile esthetics.
Korean J Orthod. 2017;47(1):59.
17. Singh DP, Arora S, Yadav SK, et al. Intraoral approaches
for maxillary molar distalization: case series. J Clin Diagn
Res. 2017;11(5):1.
18. Burden DJ. An investigation of the association between
overjet size, lip coverage, and traumatic injury to maxil-
lary incisors. Eur J Orthod. 1995;17(6):513.
19. Chaturvedi R, Kumar A, Rana V, et al. A correlation of
permanent anterior tooth fracture with type of occlusion
and craniofacial morphology. Int J Clin Pediatr Dent.
2013;6(2):80.
20. Bauss O, Rohling J, Schwestka-Polly R, et al. Prevalence of
traumatic injuries to the permanent incisors in candi-
dates for orthodontic treatment. Dent Traumatol. 2004;20
(2):61.
21. Wagaiyu EG, Ashley PF. Mouthbreathing, lip seal and
upper lip coverage and their relationship with gingival
inflammation in 11-14 year-old schoolchildren. J Clin
Periodontol. 1991;18(9):698.
22. Sharma RK, Bhatia A, Tewari S, et al. Distribution of gin-
gival inflammation in mouth breathing patients: an
observational pilot study. J Dent Indones. 2016;23(2):28.
23. Solem RC, Marasco R, Guiterrez-Pulido L, et al. Three-
dimensional soft tissue and hard-tissue changes in the
treatment of bimaxillary protrusion. Am J Orthod Dentofac
Orthop. 2013;144(2):218.
24. Tadic N, Woods MG. Incisal and soft tissue effects of max-
illary premolar extraction in class II treatment. Angle
Orthod. 2007;77(5):808.
25. Sharma JN, Kumar KHK. Orthodontic treatment of
bimaxillary protrusion malocclusion clinical report
and treatment results. Health Renaiss. 2010;7(1):54.
26. de Almeida-Pedrin RR, Guimaraes LBM, de Almeida MR,
et al. Assessment of facial profile changes in patients
treated with maxillary premolar extractions. Dent Press J
Orthod. 2012;17(5):131.
27. Maetevorakul S, Viteporn S. Factors influencing soft tissue
profile changes following orthodontic treatment in patients
with class ii division I malocclusion. Prog Orthod. 2016;17
(13). https://doi.org/10.1186/s40510-016-0125-1.
 The extraction of teeth: Part 1 diagnostic and treatment considerations
28. Oliver B. The influence of lip thickness and strain on
upper lip response to incisor retraction. Am J Orthod.
1982;82(2):141.
29. Amirabadi G-E, Mirzaie M, Kushki S-M, et al. Cephalom-
teric evaluation of soft tissue changes after extraction of
upper first premolars in class II div 1 patients. J Clin Exp
Dent. 2014;6(5):e539.
30. Kim SJ, Kim KH, Yu HS, et al. Dentoalveolar compensation
according to skeletal discrepancy and overjet in skeletal
class III patients. Am J Orthod Dentofac Orthop. 2014;145
(3):317.
31. Jerrold L, Lowenstein LJ. The midline: Diagnosis and
treatment. Am J Orthod Dentofac Orthop. 1990;97(6):453.
32. Nanda R, Margolis MJ. Treatment strategies for midline
discrepancies. Semin Orthod. 1996;2(2):84.
33. Tulloch C, Lenz BE, Phillips C, et al. Surgical versus
orthodontic correction for class ii patients: Age and sever-
ity in treatment planning and outcome. Semin Orthod.
1999;5(4):231.
34. Azamian Z, Shirban F. Treatment options for class iii mal-
occlusion in growing patients with emphasis on maxillary
protraction. Scientifica Vol. 2016, Article ID 8105163,
p. 9. 10.1155/2016/8105163.
35. McNeil C, McIntyre GT, Laverick S, et al. How much inci-
sor decompensation is achieved prior to orthognathic
surgery? J Clin Exp Dent. 2014;6(3):e225.
36. Jacobs JD, Sinclair PM. Principles of orthodontic mechanics
in orthognathic surgery cases. Am J Orthod. 1983;84(5):399.
317
37. Sun B, Tang J, Ding Y, et al. Presurgical orthodontic
decompensation alters alveolar bone condition around
mandibular incisors in adults with skeletal class III maloc-
clusion. Int J Clin Exp Med. 2015;8(8):12866. PMC4612887.
38. Cai B, Zhao XG, Xiang LS, et al. Orthodontic decompen-
sation and correction of skeletal class iii malocclusion
with gradual dentoalveolar remodeling in a growing
patient. Am J Orthod Dentofac Orthop. 2014;145(3):368.
39. Naini FB, Cobourne MT, McDonald F, et al. The aes-
thetic impact of upper lip inclination in orthodontics and
orthognathic surgery. Eur J Orthod. 2015;37(1):81.
40. Ko EW-C, Hsu CC, Hsieh HY, et al. Comparison of pro-
gressive cephalometric changes and postsurgical stability
of skeletal class iii correction with and without presurgical
orthodontic treatment. J Oral Maxillofac Surg. 2011;69
(5):1469.
41. Flores RJM. Multidisciplinary orthodontic treatment in
adult patients: the future of orthodontics. Int J Orthod.
2010;21(3):11.
42. Kokich VG, Spear FM. Guidelines for managing the ortho-
dontic-restorative patient. Semin Orthod. 1997;3(1):3.
43. Mathews DP, Kokich VG. Managing treatment for the ortho-
dontic patient with periodontal problems. Semin Orthod.
1997;3(1):21.
44. Webb CM, Rinchuse DJ. Occlusal Philosophy: Investigating
the Reasons Orthodontists Have for Occlusion Preference. Scotts-
dale AZ: Orthodontic Practice US, MedMark Pub.; March
22, 2014.