By Ashley Craig
When David* recognized his former Orthodontist while vacationing on a tropical island in 2010, he decided to confront him about his treatment as a child.
“Do you remember me?” he asked. The orthodontist shook his head. David smiled and pointed to his teeth.
“Oh, I suppose you’re a former patient,” said the orthodontist.
“Yes. Do you notice anything about my teeth?” David asked. The orthodontist shook his head.
“They’ve returned to how they were before. You really should change your treatment method.”
“Well, that’s your opinion,” the orthodontist responded.
Like many orthodontic patients, David had started with a minor case of crowding as a child. His orthodontist removed four premolar teeth and subsequently applied fixed braces to close the gaps and align the teeth. Shortly after their removal, his remaining teeth relapsed. After enduring two years of his life in braces, thousands of dollars had gone toward a still-crooked smile, now with missing teeth.
Extraction of teeth is a common practice in the dental industry. According to Orthodontist Chris Norton, over 60% of traditional orthodontic cases in the U.S. and over 80% in the U.K. involve extracting between four and eight permanent teeth. Removing teeth and straightening them into alignment may at first appear to be a simple and effective method of correcting teeth. With myriad problems resulting from extraction treatment, however, one must question whether this method is an easy way out for the practitioner rather than an optimal solution for the patient. In the short term extraction is hard on the body, with trauma to the surrounding tissue, use of anesthesia, and potential for complications such as bleeding and dry sockets. Beyond these immediate issues, extracting teeth and closing the gaps narrows the dental arch, allowing less room for the tongue and potentially reducing the volume of the posterior airway. The approach can lead to long-term conditions such as sleep apnea, and even damage the facial structure. A narrow arch provides less bony support for the face, sometimes leading to a dished-in appearance from the side as well as a narrower facial structure and smile.
The difference between extraction and non-extraction treatment is exemplified by a paper published by Dr. H.L. Eirew in the British Dental Journal in 1976. Two identical twin girls had presented with identical cases of crowded teeth.
One received extraction treatment, while the other had her palate expanded. The resulting differences are nothing short of profound.
For many years, orthodontists have practiced with the belief that we have evolved to have smaller jaws that are unable to accommodate all 32 teeth. Looking at the history of malocclusion, however, it becomes apparent that the rise of crooked teeth is closely paralleled with the rapid rise of civilization – something that has only taken off in the last four hundred years; a relative blink of an eye with the process of evolution taking millions of years. This amount of time is simply too short for our genes to have changed significantly. As such, it seems that crooked teeth are not a result of genetically smaller jaws but rather a developmental effect of our modern lifestyles.
Once we accept that narrow jaws and malocclusion are environmental rather than genetic, the focus of orthodontic treatment necessarily changes from the easy route of extracting teeth to the optimal solution of expanding the jaw to accommodate the teeth.
What About Wisdom Teeth?
Janet’s* story demonstrates how the dental industry can be overly extraction-happy. She’s one of the lucky ones, with a wide dental arch and enough room to accommodate all 32 teeth. Her wisdoms grew in straight without issue, and yet every six months at her dental check-up she receives the same advice from her dentist: “You might as well get your wisdom teeth removed; you don’t need them.”
Even if we were to accept the common “wisdom” that wisdom teeth are vestigial structures, it is alarming to think about the prevalence of wisdom tooth extraction. After all, we do not have our appendix removed unless it causes us problems. Why, then, do nearly 85% of adults go through the trauma of surgery for teeth that frequently remain dormant in the bone, or even erupt fully with no issue? There appears to be a degree of fear mongering, with experts advising patients that problems like decay, infection or cysts will most likely flare up in time. However, figures cited by organizations with a vested interest in promoting oral surgery are rarely backed by evidence. In fact, when asked by the New York Times to back up its claim that 80% of young adults who retained wisdom teeth developed problems within seven years, The American Association of Oral and Maxillofacial Surgeons could not produce supporting evidence and deleted the statement from their website. Critics of routine extraction cite many studies, among them one that found complications occurred for only 12% of 1,756 middle-aged people who did not have their wisdom teeth removed.
Perhaps many of us get along fine without our wisdom teeth, but are we really in optimal condition without them? It’s certainly a thought to chew on.
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Then Chris Norton was either a liar or a fool. Never in my career have premolar extractions been done in over 25% of the orthodontic cases in the US, if that. Orthodontics in the Begg School were overzealous in premolar extraction, but they were always a minority of US orthodontists. NEVER has any philosophy advocated extraction of eight premolars. That would be WIPING PATIENTS OUT OF ALL PREMOLARS! Never are patients so crowded they need that much space to erupt their canines.
Talk about constructing a straw man for an argument!
None of you can seem to fathom the difference between decrowding and/or detorquing incisors, and bodily retraction, which hardly happens at all. One can only move teeth in the confines of the bone. Also, you cannot really even restrain the growth of a maxilla without 24 hour headgear, which we seldom even tried 30 years ago. You think it happens all the time and it doesn’t. It is easy enough to assess on ceph by means of the measurement Nation perpendicular.
And as I told you, a peer-reviewed study showed no arch width difference at all with or without extractions.
However, never let facts get in the way of good propaganda.
Wow, I wonder what all these have in common? Retraction, restriction, underdevelopment….
The term “often” is used to dismiss those who don’t fit the ’evidence’ mould. All of those you have listed ‘often‘ manifest themselves later in life due to years of struggling to breathe with forward head posture, inadequate tongue space, years of biting in the wrong jaw position, an underdeveloped maxilla due to extractions as a child, mouth breathing because of narrowed airways… the list goes on.
Kim – You’re just not getting it and, with your attitude, sadly you never will.
Geez, we did full body dissections on cadavers in school, two quarters on the head and neck alone. More than the medical students did, in fact! Yet I don’t know who the components of the head and neck are arranged. But you do! Go figure.
There is no scientific evidence for anything you state. Please provide some for us. Nonsense from conspiracy websites do not count.
Like TMJ, breathing problems manifest themselves later in life, and are often caused by pharyneal muscle collapse that comes with age, or chronic allergies.
This closed and constricted attitude you have is exactly why these mutilations are still happening now. Your responses give an insight into what type of mind you have. Blinkered and unwilling to consider anything outside of your own thinking.
Congratulations on being an internet conspiracy theorist guru. More power to you, son. My education and experience is nothing compared to your superior intellect. You and Dawn really need to get together and spawn a race of geniuses.
As I have said many times before, many people including me have forward head posture, and never had extraction orthodontics. Mine was caused was hunching over a table building model airplanes as a child.
If you claim your jaw is “posteriorly positioned” to damage your cervical discs, I am sure you can post your traced ceph here to back up your claims.
If you are an orthodontist, I fear for your patients.
You, my friend, are OUT OF YOUR MIND.
Premolar extractions are only done in children that age in VERY crowded cases with no chance of success non-extraction. Usually cases where the canines, and even lateral incisors, are totally blocked out of the arch.
There is no affect on arch width. None. In fact, one study showed a .7mm lower arch inter canine INCREASE in width. Because the canines were moved backward where the arch was wider.
Since my last post, I have read through quite a few articles, and will share them with you if you want. One submitted photos of smiles to laymen and dentists. The viewers were supposed to come up with which were extraction cases and which were not. There was zero accuracy with dentist and lay people. Orthodontists had only a 5% predictive success.
Another study showed no dished-in faces or reatraction of arches on ceph, UNLESS EXTRACTIONS WERE PERFORMED ON A PATIENT WHERE ARCH LENGTH WAS CLEARLY SUFFICIENT. In other words, in cases where extractions were not warranted.
Another study compared condylar position on x-ray in the fossa between extraction ortho cases and controls. No differences were noted.
As to TMJ, it usually develops later in life. A study showed that people with orthodontic treatment, WHETHER OR NOT BY EXTRACTION, have a lower incident of TMJ, not a higher one.
You might be interested to know that the father of American orthodontics, Tweed, taught all orthodontics without extraction from 1907-1920. His students noted their many patients’ tooth alignment was unstable and soon started to collapse after treatment ended. Angle’s most famous student, Tweed, was generous enough to retreat the worst relapsed cases by extraction, and got much better results. Thus the era of extraction orthodontics begun.
Extraction therapy peaked with Begg orthodontics, and declined with the use of Hyrax and enamel reduction. But non-extraction therapy is still impossible with many patients. Even if do-able, the result is not stable.
You are out of your mind if you think C5/C6 disc problems have anything to do with orthodontics.
I am speaking from personal experience of premolar extractions at the age of 9, which had a negative effect on the growth of both my mandible and maxilla. When you remove the tooth of a child, the body absorbs the bone, so your bone growth is stunted – it is unable to develop fully because it doesn’t have to accommodate the pulled teeth.
So, I had four teeth removed at age nine (again, denied the right to grow fully) and then given braces which pulled both arches back, accompanied with elastics. My mandible has been trapped far back from where it naturally should be positioned. The result is that I have had consistently forward head posture and strain on my neck throughout my life from biting back from where I should have been.
I am now 37 with a herniated cervical disc at c5/6 from the pressure of an improperly placed jaw – a direct result of extraction/ retraction orthodontic treatment. I am now resisting neck surgery for fear of paralysis.
It absolutely infuriates me how you keep going with your denial that extractions as a child is fundamentally wrong and that it stunts growth.
What do you say to all those people who had extractions as a child and are ridden with adult health issues? It’s all in your head because “the evidence” doesn’t fit that mould? Well, I do not care if I don’t fit your mould and the evidence you speak of. I speak from personal experience, and I’ve had the sense to equate my personal health issues to the position and size of my jaws.
The nature of the bone changes with age. It becomes less dynamic and less flexible with more years. How well I find this out every time I do implants or extract wisdom teeth.
The lower jaw grows at the condyles. There is no growth center in the middle of the mandible. There is a suture in the middle of the maxilla that can be expanded less and less with age.
In extraction cases a problem is closing all space between the premolar and molar. If we manage to do it, sometimes it opens back up later. This is no disaster.
The WIDTH of the jaws pre-puberty is determined by the force of the tongue inside counteracted by the force of the cheeks from the outside. This is the principle of the old Frankel appliance. Once again, I say for all practical purposes that it is impossible to widen the mandible much past puberty. If the arch is expanded within the body of the mandible, it will be unstable and relapse.
I am sorry, but in adulthood you can push with your tongue all you want, but probably won’t achieve any increase in mandibular width. But how many hours a day could you spend pushing your tongue from side to side, anyway.
Airway problems influence growth. Restricted airways cause the tongue to be positioned lower and more forward, so it changes vectors of force applied to both maxilla and mandible. We really have no way of knowing how much GROWTH is genetically determined versus AIRWAY PROBLEMS genetically determined. It is not uncommon to see 3 generations of humans with allergies and airway problems. Predictably, they have the same misdirected growth.
Interesting to me is that groups with space excess in the arches to fit all teeth and then some, usually have large and muscular tongues, as well as flaccid lips. This is no coincidence.
What about the arches though? How can an arch expand if there are braces or a retainer in place? Then widening of the face is impossible with braces because the teeth can’t move.
I wore braces from the age of 13 to 15 and a retainer for the next 4 years, which I deeply regret about. It wasn’t my decision anyway. I actually didn’t want to wear them.
Because the teeth were at an exact same place these 4 years, so my chin had no reason to widen. The pre-molars and molars moved apart a little bit in both my upper and lower arches after the braces where taken off, but the incisors and canines stayed in one place due to the retainer on my lower arch. This is not to say that the maxilla and lower jaw had no reason to widen for the 2 years of wearing the braces.
Correct me if I’m wrong, but these are the conclusions that I came up with based on the information that I have read.
Speaking of shoes, if you were an adult and had finished growth, and you wore tight shoes, would it make your feet smaller? No, because growth was completed and you can’t influence it anymore. All it would do is cramp your toes and cause blisters.
Palatal expansion is not a “new” technique. There is nothing “new” about TRYING to direct and potentiate growth. I have done it all my career. But it has its limitations, and timing is critical.
For the millionth time, premolar extraction does not appreciably influence the width or length of the maxilla or mandible. It typically makes room so the anteriors can be decrowded. Any extra space is consumed by translating molars forward, which often makes room for wisdom teeth to erupt.
For goodness sakes, stop with the “extraction pushes the jaws backward and impinges on the airway” nonsense. There is no net forward or backward force on the maxilla with extraction mechanics. The forces applied WITHIN the maxilla counteract one another. The only way to influence maxillary position is by 24-hour headgear. Kids never cooperated in wearing it that way, and we have not used headgear in about 20 years.
Having new techniques nowadays which enable palate expansion in order to accommodate the teeth DOES NOT excuse the removal of teeth in the past.
You state modern jaws are smaller. Then why on earth would you make them even smaller by extracting teeth?!
When I traced cephs post-operatively all all patients, I never detected any appreciable increase in mandibular plane angle. Even brachyfacal patients, which would look better with longer faces, are hard to achieve mandibular plane angle increases.
The way you would get appreciable mandibular plane angle increases was trying molar distalizations on clockwise growers. That is why we were taught to do extractions rather than molar distalizations in crowded high mandibular plane angle patients. Sure don’t want to open the mandible anymore by distalizing molars. Of course if the arch is constricted and the patient has the potential, I will expand the palate using a Hyrax with the mandible as a template as to how far I can expand.
In the old days we tried to treat high mandibular plane angle patients with high-pull headgear. Cooperation was alway dicey. With high-pull seldom if ever used, I’m not sure anyone tries to control the vertical anymore. Just wait until surgery is possible if the patient wants it fixed.