Crowding
Extractions and the facial profile
It has been claimed within parts of the dental profession that the extraction of teeth prior to orthodontic treatment leads to a flattening of the facial profile. However, many patients for whom no teeth were removed have lips that are set back at the end of treatment (because they always had a flatter profile). Conversely, many patients who have had four teeth removed have teeth and lips that are forward at the end of treatment. These paradoxes show that the issue is not black and white but much more complex. When the dentition is crowded, it is sometimes necessary to extract teeth to make space but, at other times, additional space can be created by widening the dental arch or guiding the front teeth further forward to accommodate the crowded ones.
The removal of premolars does have an effect on the profile, but less than might be expected. An interesting study was carried out in the US by examining a sample of very similar patients who were borderline extraction cases. Half were treated with extractions and half without, and their profiles were compared 15 years later. The long term outcome was that the front teeth and lips of patients who had extractions were just 2mm further back than the non-extraction patients, the difference between the groups being no more than the thickness of a 10 pence coin. The teeth of the extraction group had also remained straighter over the 15 year period. An essential feature in this study is that both groups of patients were treated to high standards by specialists with fixed braces.
When crowding is more severe, the extraction of teeth does not have any effect on the fullness of the lips. The facial profile is only harmed if extractions are undertaken following inadequate assessment or if treatment is undertaken with insufficient control of the appliances.
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