An inventor seeking to produce a perpetual motion machine might get advice from orthodontists who have successfully kept the extraction/non-extraction debate in motion for well over a hundred years. As a brand new orthodontic resident at the University of Minnesota, I assigned myself the task of reading and scanning all the refereed literature going back to the early 1900s. It wasn’t hard to find descriptions of sometimes animated debates over the merits of removing or not removing permanent teeth as part of orthodontic care. As a rookie in the profession in 1972, it seemed odd that this debate — begun in 1911 with Drs. Case and Dewey — was still raging. The debate continues now in 2026, 115 years later. In real world terms this seems to be approaching an eternity. Now with 54 years in the profession in the rear view mirror, I frankly laugh and cry at the same time.
As the son of a University of Illinois Electrical and Nuclear Engineering Professor who raised me to seek proof for everything, I avidly looked for the science in the orthodontic profession that should have settled this debate once and for all. How hard would that be to do? Look at whatever solid research there is, have a debate, and come to a conclusion. Surely there is solid science creating evidence-based rules underlying the profession. Well — good luck with that. I have one article I cite in my lectures from a dentist in academia stating that about 8% of what we do in dentistry is “evidence-based.”
Orthodontic residents are taught that reason #1 for extraction is that cases are more stable. Despite numerous studies published in the literature, this rule has never been validated even once. Virtually all orthodontists recommend some type of “forever retention” regimen, which would render this argument moot. When the patient stops wearing the retainer many years after treatment and the teeth shift, it is deemed “the patient’s fault.” Does this reason for extraction actually make sense?
Reason #2 for extraction is that moving teeth forward or laterally without removing teeth “violates the well agreed upon biological limits of the periodontium which can cause recession and tooth loss.” That reason scared me enough that the crooked teeth I married stayed that way for 11 years. Only after I began to question virtually everything I learned in my training did my wife and I decide to align her teeth without removing any. Not only did we move them forward substantially, but we expanded her arches non-surgically about 10 mm — and without MARPE, long before anyone had used temporary anchorage devices in orthodontics.
After 55 years of marriage she has very minimal recession and amazingly hasn’t lost any teeth to recession. As the treatment coordinator in my ortho practice, people often said, “I want a broad, full smile like your wife.” Any 10-year-old with a mobile device could find the 7 articles from the refereed literature I cite in lectures confirming that it is possible to substantially advance teeth without removing any and not cause recession or tooth loss. I’ve treated literally thousands of people since the early 1980s without extractions and without causing tooth loss. It is nice to have the refereed literature support what my brain told me was good treatment decades ago.
Recent detractors in the literature cite patients who have lost teeth due to the FAGGA appliance as a reason to extract. What they fail to mention is that any such treatment of a person with existing periodontal disease with recession is unwarranted. What they further fail to mention is that treatment done in the primary dentition — like our ancestor orthodontists did over 100 years ago — might have avoided any future orthodontic treatment.
Reason #3 often given is that the patient will have a profile that is too full if teeth are not removed. Orthodontists draw a line from the chin to the nose and diagnose “bimaxillary protrusion” if the lips are ahead of this line. This is a measurement that has never been scientifically validated for use in any ethnic group, but that is apparently immaterial.
Almost universally, the fact that most patients who are so diagnosed also have chins that are recessed — often by more than 2 standard deviations — is overlooked entirely. That recession would make the lips appear too full. One must also consider that certain ethnic groups have much shorter noses than Caucasians, who were the predominant orthodontic population in the 1940s when this measurement was introduced. African-American and Asian patients are therefore more frequently diagnosed with “bimaxillary protrusion” and are prescribed the cure of removing four bicuspid teeth. One of the patients who came to me for reversal of her extraction treatment said, “They didn’t respect my ethnicity.”
Now that we have dealt with the three most common reasons to extract, let us examine something far more important. Do you like to breathe? Do you think the space for your tongue will get bigger or smaller if you have teeth removed and have the front teeth retracted? Do you think it would be better to have a bigger or smaller airway?
I have over 3 decades of experience treating patients unhappy with the esthetic and functional results they feel were caused by extraction treatment. Having re-opened previous orthodontic extraction spaces for a patient and having sleep reports before and after to prove elimination of OSA (Obstructive Sleep Apnea), I have my thoughts on this as well. For over 15 years I’ve used a slide in my lectures on this issue. It says, “Do you think it is possible to retract enough to cause OSA?” In dozens of audiences — some numbering in the hundreds — not one person has ever said it would not be possible. The next question I ask is: how far can you retract before causing a problem? No one has ever told me the answer. In all my decades of experience in the airway arena, I have not figured that out either.
I have 6 articles from the refereed literature stating that the airway is smaller with extraction/retraction treatment. Would you agree to treatment of any kind that would reduce your airway or that of your child? Do you think this debate should have been settled long before now?
What if there were treatment approaches done in the primary dentition that would eliminate the consideration of extraction orthodontic treatment and its resultant change to the airway? What if you were able to treat a child in the primary dentition and never need further orthodontic treatment? Would you be interested in this for your child or your patients? Would you rather wait until adolescence for treatment and then engage in the extraction/non-extraction debate that still rages in the profession? You decide.
