4 Premolar extractions: worried about face/TMJ, have had multiple opinions, 3 say extractions, 1 says no extractions (photos)

Question

The lst one wants to remove 4 bicuspids for my severe crowding. The 2nd orthodontist told me that I wouldn't need extractions and that all I would need is to expand the jaw to make room for the teeth. The 1st orthodontist said that my case can't be done w/o extractions because of lack of bone to move things around. He said if I got work like that done I'd look fine initially but in 5-10 yrs, it would push my teeth out of the bone and I would have severe gum disease. Help! What should I do?

Robert Waxler, DMD, MS · Answer

Premolar Extractions Controversy

There is probably no facet of
orthodontic treatment that has caused as much controversy as the decision to
extract, or not to extract, permanent teeth: and more specifically, whether to
extract four premolars or to “develop” room for non-extraction treatment.

Besides the obvious reasons of avoiding the trauma and
expense of surgery, and the desire to preserve permanent teeth; other alleged
negative sequela, such as TMD problems, flattened facial profiles, and “dark
buccal corridors” have contributed to the premolar extraction controversy. Like
a pendulum, the popularity of premolar extractions has swung back and forth,
between the extremes of non-extraction at any cost and “routine” extractions to
achieve arbitrary cephalometric norms.

Some of the factors we consider
are:

When dealing with a fairly “normal” orthodontic
     problem (no gross asymmetries) the decision to extract four
     premolars is straightforward although often not easy. It is impossible to
     extract less than a whole tooth, and usually the extraction of a tooth on
     the left requires an extraction on the right to balance the midline.
     Likewise, lower extractions usually require upper extractions (and visa
     versa) to prevent excessive overjet or underbite. These parameters
     normally lead to extraction of four first premolars or to treat as a
     non-extraction case. There are times when upper premolars only, a single
     lower incisor extraction, molar extraction, or interproximal enamel
     reduction (IPR) are appropriate but, in general, the decision for
     extractions is often framed around “4-bi’s”.

Given the usual all or nothing nature of the
     premolar extraction decision, it is no surprise that different
     orthodontists often appear to have conflicting treatment plans for
     the same patient. The reason is not that they see very
     different problems or have radically different philosophies of treatment,
     but rather that each doctor has a different line in the gray area between
     extractions and nonextraction. Two treatment plans that appear very
     different can both be based on a similar analysis of the patient’s
     problem, but end up with very different treatments due to the black and
     white nature of the decision making process.

It is important to understand that in borderline
     cases there are no correct or right answers. Both treatments
     performed by competent orthodontists would produce a good result, but
     neither is perfect. Each option would have pros and cons, and
     orthodontists and dentists could (and do!) spend endless amounts of time debating
     which option is “right”.

We try to avoid extractions as much as possible, but extractions should be considered when
     esthetics and stability call for it. 
     Truthfully, almost any patient can be treated without
     extractions and, often, this is technically the easier way.  This is the reason that the weekend
     orthodontic courses aimed at general dentists almost always stress
     nonextraction treatment.

Where there is a conflict between
     facial esthetics and dental stability, it is our judgment to favor esthetics. 
     This is not to say that patients with flat facial profiles and
     extreme crowding should be treated without extractions, nor that patients
     with full profiles and large tongues should have teeth extracted, but
     rather that esthetics should be the primary determinant of treatment in
     any borderline situation.  In these
     cases it is very important that the patient understands the necessity of
     long-term retention

Contrary to the beliefs of many nonextraction
     proponents, good scientific studies (evidenced based) done on TMD and
     orthodontic treatment fail to show any correlation between the
     development of TMD type problems and the extraction (or
     nonextraction) of teeth.  All
     dentists can remember patients who develop TMD problems after extraction
     treatment and, if you feel there is a correlation, you will fixate on
     these patients.  Statistically, you
     are just as likely to find TMD problems in patients treated nonextraction
     or, for that matter, patients who never received orthodontic treatment at
     all.

Scientific studies have also shown that well
     treated extraction cases do not adversely affect facial profiles.  Again, it
     is easy to visualize patients with flat profiles who have had premolar
     extractions.  Assuming a good
     treatment decision, these patients would have had a flat profile even if
     they never had treatment (and an extremely unstable dental alignment if
     they had been treated without extractions). The truth is: tight facial
     structures (flat faces) lead to crowding, which leads to extraction rather
     than extractions cause flat faces. As a matter of fact, the most dished in
     and flattened faces often belong to those patients whom we have treated without
     any extractions. Like the TMD controversy, negative esthetic effects
     attributed to extractions fall into our favorite logical fallacy “post
     hoc ergo propter hoc” (after this therefore because of this).  Other studies have also shown that dark
     buccal corridors and a narrow smile are not “caused” by premolar
     extractions.

A good selling point for premolar extractions can
     be a patient with moderate crowding and well-formed and positioned third
     molars.  Treated without premolar extractions
     this patient usually needs third molars removed. Extract premolars, close
     some of the space by mesial movement of the posterior teeth, and hopefully
     the thirds can erupt and be kept—an exchange of four small, easily removed
     teeth for four molars that would be difficult to extract. Unfortunately no
     guarantee can be made that the thirds will always come in with enough
     room.

There seems to be a great deal of confusion about
     early expansion treatment (AKA arch development or growth
     modification).  There is a important
     difference between expanding a constricted upper arch to match a normal
     lower arch (OK) and significantly expanding both arches in a patient whose
     arches may be narrow, but are in a normal transverse occlusal relationship
     to each other (not OK).  Although it
     is possible to upright lingually verted lower posterior arches (which may have
     collapsed in, to compensate for a narrow maxillary arch), it is not
     possible to expand the mandibular basal bone, as there is no suture to
     distract as in the maxilla.  Of
     all the inviolate “facts” of orthodontics, one of the most established is
     the stability of the lower inter-canine width.  Expansion beyond the original width is
     almost a guarantee of collapse and recrowding.

Every decade or so a new “magic bullet” comes
     along promising the ability to create space and avoid extractions or
     unstable expansion.  The latest
     iteration of this is the Damon&trade; orthodontic bracket with its
     manufacturer’s promise of extremely light forces that “grow” more room
     than regular braces.  As usual, no
     good science backs up these claims!

In an attempt to avoid first
premolar extractions, various alternatives can be considered:

oExpanding the arch, especially in a flat-faced
individual, is often preferable to extractions, with the understanding this is
an unstable correction and perpetual detention will be needed.

oFor
patients with a good posterior occlusion, a good upper arch with relatively
small upper incisors, moderately severe lower crowding, and minimal overbite,
the extraction of a lower incisor can be considered. Extraction
of an incisor should be evaluated very carefully, for it can result in an untreatable
problem with excessive overjet/overbite in the wrong individual.

oInterproximal
enamel reduction (IPR)
can provide a moderate amount of room but should be reserved for older
patients. Excessive IPR as an initial treatment complicates the orthodontist’s
ability to correct minor relapses in the future.

oConsider
extraction of second premolars rather than first premolars.
Theoretically, this reduces the amount of anterior retraction when only some
space is needed for crowding and the facial profile is acceptable.  This works best when the second premolars
resemble the first, but large, molar-like second premolars may provide too much
room and small, canine-like first premolars may not work against first molars.

oDistilization
of full arches is very difficult so extraction of third molars or even second
molars to provide anterior room has never been shown to provide significant
space.  With the advent of temporary
anchorage devises (TAD’s) this may become a “new” way to treat
nonextraction…. we’re already trying it!

Bottom line: Extractions are just a tool, not good or bad
in themselves.  Used right, they improve
the quality of treatment, used wrong they may create a poor result.

4 Premolar extractions: worried about face/TMJ, have had multiple opinions, 3 say extractions, 1 says no extractions (photos)

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4 Premolar extractions: worried about face/TMJ, have had multiple opinions, 3 say extractions, 1 says no extractions (photos)

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