Straight talk about extraction and nonextraction:

A differential diagnostic decision

James L. Vaden, DDS, MS, and Hubert E. Kiser, DDS
Cookeville, Tenn., and Bluefield, W. Va.

At one stage or another, orthodontics is usually a space management procedure, particularly during
the correction of a Class I or Class II malocclusion. Orthodontists use space that is available or
create space to correct malocclusions. There are anterior, posterior, lateral, and vertical dimensions
of the dentition and its supporting structures. If the muscular balance is normal, the clinician should
try to respect these dimensions. The orthodontic clinician should not be an extractionist or a
nonextractionist. Rather, the clinician should use differential diagnostic skills and artistic ability to
arrive at the most appropriate treatment outcome for each patient. (AM J ORTHOD DENTOFACORTHOP
1996; 109:445-52.)

B e c a u s e orthodontics involves space man-
agement, clinicians must thoroughly understand
the concept of dimensions of the dentition (or
denture). Diagnosis and treatment are four dimen-
sional. There is an anterior dimension or boundary,
a posterior dimension or limitation, a vertical di-
mension and a lateral or transverse dimension.
THE ANTERIOR DIMENSION
Tweed T M defined the anterior limit of the den-
tition for the specialty of orthodontics. He devel-
oped the diagnostic facial triangle and demon-
strated that one could improve facial balance, as
well as stability, if proclined mandibular anterior
teeth were uprighted over basal bone. Tweed knew
that a patient who had a low Frankfort mandibular
plane angle might not need as much mandibular
incisor uprighting as the patient with the higher
Frankfort mandibular plane angle. Even in the
"low angle" patient, the mandibular incisors should
not be pushed forward from their original position
if the muscular balance is normal. Therefore, for
the patient with normal muscular balance, extrac-
tions are often necessary if the anterior limit of the
dentition is to be respected in the presence of
significant anterior crowding and/or protrusion.
THE POSTERIOR DIMENSION
The posterior area of the mouth and the space
available in the posterior area of the mouth is disre-
garded by many clinicians. Teeth are driven back
Copyright © 1996 by the American Association of Orthodontists.
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into this area with little thought given to how much
space is available for them. Merrifield,5 Richard-
son, 6"7 and Leygard8 have given the specialty some
very good guidelines about how much space is actu-
ally available. Observe the eephalometric x-ray film,
made 8 months into treatment (Fig. 1) of a patient
whose treatment was started without extraction. The
second molars are hopelessly impacted. This patient
cannot be treated without extraction if the posterior
area of the mouth is to be respected. The patient's
recall film after second premolar and third molar
removal (Fig. 2) confrms second molar eruption and
function. Pretreatrnent and posttreatment photo-
graphs confirm that facial balance was protected
(Fig. 3), and that the posterior discrepancy was ad-
dressed.
Third molars are teeth. When discussing the
posterior dimension of the mouth, it is important to
note that when nonextraction treatment is touted, 32
teeth must be maintained in the mouth. The extrac-
tion of third molars is a therapeutic decision. If a
patient has to have third molars extracted, it is ex-
traction treatment, not nonextraction treatment.
THE VERTICAL DIMENSION
Merrifield,9,1° Pearson, r1,12 Radziminski, 13
Schudy, ~" and many others have written extensively
in the literature about the vertical dimension. If the
vertical dimension is increased in the posterior area
of the mouth, a longer face is created. There may
also be more gingival display on smiling. Also, if
maxillary posterior teeth are driven distally to cor-
rect Class II malocclusions when no space is avail-
able, there is a "wedging open" effect in the ante-
445
446 Vaden and Kiser American Journal of Orthodontics and Dentofacial Orthopedics"
April 1 9 9 6

Fig. 1. Eight-month cephNometric x-ray film.

Fig. 3. Composite facial photographs.

Fig. 2. Posttreatment cephalometric x-ray film.

rior vertical dimension that creates a longer face.

Merrifield 15 found that for every 1 mm of vertical
expansion in the molar area, a 1.3 mm increase in
anterior facial height occurred.
Patients who need extractions but who are
treated without them are very often expanded ver-
~t
tically. Point B drops down and back (Fig. 4). Poor
# /~ iI
facial esthetics is the result. Except in patients with I //
deep bites who have poor vertical development, it
is crucial to preserve the vertical dimension if
stability, as well as facial balance and harmony, are \\'~ i
the ultimate goals.

T H E LATERAL D I M E N S I O N
Point p Drops
Down and Back
Lateral expansion is touted in many circles.
%i
Lateral expansion works if you believe in perma- /f ~j " x,
nent retention. Strang, 16'~7 one of our specialty's
pioneers, studied lateral expansion. Strang con- Fig. 4. Downward and backward movement.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 109, No. 4
Fig. 5. Pretreatment casts: nonextraction patient.
cluded that it was to be avoided at all costs. Study
the 1981 article by Little, Wallen, and Riedel. 18The
dentitions that exhibited the most relapse were, in
most instances, the ones that had undergone the
most mandibular canine expansion.
In today's world, orthodontists hear a great deal
about expansion in the mixed dentition. Little,
Riedel, and Stein l~ published an article about in-
creasing the mandibular arch length in the mixed
dentition. They reported that early arch length
expansion was a failure 87% of the time.
Consider the so-called "borderline" patient.
Paquette, Beattie, and Johnston 2° studied a sample
of borderline patients treated without extraction. A
statistically similar sample was treated with first
premolar extraction. The authors concluded that
there was nothing wrong with extraction in the
"borderline" patient. In the extraction sample, the
teeth that were extracted were first premolars, but
probably these patients had midarch problems and
could have been better treated with second premo-
Vaden a n d Kiser 447
Fig. 6, Pretreatment casts: extraction patient.
lar extraction. The "wrong" teeth were removed,
and yet, these patients were not "sick."
The following patients' records illustrate the
point that differential diagnosis should lead to the
extraction if necessary of selected teeth. One pa-
tient was treated without premolar extraction, the
other was treated with extraction of maxillary first
premolars and mandibular second premolars. The
casts exhibit similar malocclusions (Figs. 5 and 6).
The pretreatment cephalometric x-ray tracings
(Figs. 7 and 8) confirm good skeletal patterns. The
mandibular anterior teeth are upright over basal
bone. Study the posttreatment tracings (Figs. 9 and
10). Note the protrusion that was created in the
patient treated without extraction. Both the ante-
rior and the posterior limits of the dentition were
violated. The lateral views of the posttreatment
casts (Figs. 11 and 12) illustrate the expansion and
448 Vaden and Kiser American Journal of Orthodontics and Dentofacial Orthopedics
April 1996

1MPA 108°
SNA 8 4°
SNB 79~
ANB 5=
OCC 10 o
Z 7 2°
?FH 49mm
AFH 70ram

Fig. 7. Pretreatment cephalometric tracing: nonextraction pa-

tient. Fig. 9. Posttreatment tracing: nonextraction patient.

FMA 2 5°
FMIA 7 0~
1MPA 85 °
$NA 73.5o
SNB ~°
ANB .5~
CO= 7°
Z 7 8°
PFtt 53ram
AFH 64mrn

PFH 47mm
AFH 60mm
Fig, 8. Pretreatment cephalometric tracing: extraction patient.
resulting poor occlusion on the nonextraction pa-
tient and the interdigitation of the teeth on the
extraction patient. Study the composite tracings
(Figs. 13 and 14). Note the downward and back-
ward mandibular rotation that took place on the
nonextraction patient. The extraction patient expe-
rienced downward and forward mandibular devel-
opment. Observe the lower lip eversion and soft
tissue imbalance on the nonextraction patient (Fig.
15), whereas the extraction patient has improved
facial balance (Fig. 16). The nonextraction patient
was expanded anteriorly, posteriorly, vertically, and
laterally. There was no respect for the dimensions
of the dentition. A good differential diagnosis
would have led to a choice of extraction of teeth
other than first premolars for this patient.
Observe the composite tracings (Fig. 17) and
the pretreatment and posttreatment facial profile
photographs (Fig. 18) of this patient from whom
third molars were extracted. The point is that there
are 16 teeth in the mouth other than the first
premolars and the 12 anterior teeth that can be
Fig. 10. Posttreatment tracing: extraction patient.
chosen for extraction. Differential diagnosis is the
key.
Recently, Luppanapornlarp and Johnston 21
published a study of a clear cut sample of extrac-
tion patients who were compared with a sample of
clear cut nonextraction patients. These authors
concluded, like others before them, that there is a
long-term 2 to 3 mm arch length reduction for most
patients. After discussing this arch length reduc-
tion, the authors state "As a result, the extraction
patients improved, whereas the non-extraction pa-
tients worsened; the between-treatment differences
were statistically significant and large enough to
allow the originally crowded and protrusive extrac-
tion patients to achieve parity with their much less
severely affected non-extraction cohorts. Moreover,
the extraction patients were treated without any
mean collapse of the maxillary intercanine width,
and, more to the point of this discussion, the
non-extraction patients were treated without re-
sorting to routine expansion. Given this conserva-
tive approach to treatment, our data may underes-
timate the arch-length reduction that would be
American Journal of Orthodontics and Dentofacial Orthopedics Vaden and Kiser 449
Volume 109, No. 4

Fig. 11. Posttreatment casts: nonextraction patient.

seen following more aggressive non-extraction Fig. 12. Posttreatment casts: extraction patient.
therapy."
Differential diagnosis impacts facial esthetics. / t'
A universal and simple guideline for balance of the
lower face is that the profile line bisect the middle > t 1 ,

of the nose. 22"23 Orthodontists can influence the

profile line's relationship to the nose with treat-
ment. If the lips are protruded, the profile line will
lie outside the nasal contour. The objective should
be to reduce the protrusion and move the profile \ ~ - 7 , .'. )
line into the nose (Fig. 19). Selected extraction to
upright mandibular incisors is one way this can be
accomplished if the skeletal pattern is normal.
However, if the pretreatment profile line is
Fig. 13. Composite tracings: nonextraction patient.
"in the nose," the objective should be to main-
tain facial balance and harmony. If this den-
tally crowded patient (Fig. 20) had been treated effects of extraction on the profile and made the
without extraction of premolars, a facial protru- following statement: It should not be inferred,
sion would have been the result. Second premolars however, that the extraction profiles were too "flat"
were removed. The key words are differential diag- on recall. Instead, it was the non-extraction pa-
nosis. tients who tended to have concave faces, whereas
Again, Luppanapornlarp and Johnston = had the extraction patients more often had what non-
some interesting comments about extraction and its extraction advocates might call a "nice, full, pleas-
relationship to the facial profile. They discussed the ing profile."
450 Vaden and Kiser American Journal of Orthodontics" and Dentofaciat Orthopedics
April 1996

tT-

s /'

Fig. 14. Composite tracings: extraction patient.

Fig. 16. Pretreatment and posttreatment facial photographs:

extraction patient.

@? , ,,

Fig. 17. Composite tracings: third molar extraction.

7
Fig. 15. Pretreatment and posttreatment facial photographs:
nonextraction patient. Study the figures and percentages from the
practice of one of the authors. The figures reflect
the diagnosis and treatment of 3600 patients from
1963 to 1993. The extraction percentage was
How the clinician decides when to extract and
60.4%. The nonextraction percentage (excluding
when not to extract is a matter that should depend
third molars) was 38.5%. After careful differential
on the needs of the patient. All orthodontists
diagnosis the different extraction patterns were as
prefer not to have teeth removed. After all, orth-
follows:
odontists are dentists who are trained to save teeth.
But many diagnostic decisions require that teeth be
~44 4 4~54 5 5 6 6 4@_4__ 5~@45 Misc.
removed to preserve the dentition and achieve the
widely accepted objectives of esthetics, health,
function, and stability. 49.2% 2.9% 3.6% 1.7% 11.5% 2.6% 28.5%
American Journal of Orthodontics and Dentofacial Orthopedics Vaden and Kiser 451
Volume 109,No. 4

Fig. 18. Pretreatment and posttreatment facial photographs:

third molar extraction.
Fig. 20. Second premolar extraction. Pretreatment and post-
treatment: profile line.

The miscellaneous category consists of patients

with teeth already missing, injured, or asymmetric
extractions. The first premolar teeth were removed
from only 31% of the 3600 patients.
The average treatment time for this group of
patients, all of whom were treated with banded
appliances, was 18 to 20.5 months. Patients treated
without extraction generally had 2 months less time
in treatment than did the extraction patients.
These percentages do not reflect an extraction
philosophy or a nonextraction philosophy. They
reflect a desire to treat each patient in an indi-
vidual manner after making a careful diagnosis.

CONCLUSION
In summary, no orthodontist should be an ex-
tractionist or a nonextractionist. Orthodontists are
primarily specialists in space management. Without
proper space management, orthodontic patients do
not receive a high quality service. Our ultimate goal

Fig. 19. First premolar extraction. Pretreatment and posttreat-

ment: profile line.
452 Vaden and Kiser
should be to give our patients the highest quality of
service in the shortest period of time for the most
reasonable fee. We cannot meet this goal if our
treatment is determined by our bracket design, our
ability or lack thereof to manipulate arch wire, or
our personal biases. Orthodontics is a science as
well as an art. An orthodontist must use every tool
at his/her disposal to give each patient a treatment
result that is esthetic, healthy, functional, and
stable. To reach this goal is impossible if the
specialty eliminates its two greatest assets: (1) a
scientific differential diagnosis that may or may not
lead to extractions, and (2) the clinician's artistic
ability.
REFERENCES
1. Tweed CH. The application of the principles of the edge-
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sion: part 1. Angle Orthod 1936;6:198-208.
2. Tweed CH. The application of the principles of the edge-
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Angle Orthod 1936;6:255-7.
3. Tweed CH. Indications for the extraction of teeth in ortho-
dontic procedures. AM J ORTHOD ORAL SuRG 1944;30:405-
28.
4. Tweed CH. The Frankfort-mandibular incisor angle
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5. Merrifield LL. Differential diagnosis with total space anal-
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6. Richardson ME. The effect of the mandibular first premolar
extraction on third molar space. Angle Orthod 1989;52:
291-4.
7. Richardson ME. Development of the lower third molar
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9. Merrifield LL, Gebeck TR. Analysis: concepts and values,
part II. J Charles Tweed Found 1989;17:49-64.
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Reprint requests to:
Dr. James L. Vaden
308 E. First St.
Cookeville, TN 38501