Some dental practitioners have learned that if you pull teeth out for braces, you could end up compromising not only the airway, but the cervical spine as well. What happens with an excision (extraction) of a tooth is that the face tends to draw back, which puts pressure on the airway- it basically causes the face to collapse backward, thus closing the airway more. In addition, this effect of collapsing the face backward changes how the skull sits on the neck, the cervical spine. Now imagine that if the cranial bones are not level and you pull out a tooth. This could cause the skull to become more asymmetrical, which could lead to more head and neck pain. It’s all connected- if you pull a tooth, or two, or ten, this could mess up your whole body. Sorry to be so technical, but hopefully you see the logic.

An awful analogy to this is that if you break your finger, you really do not want to amputate it, do you? It just does not make much sense. For some reason, human beings became complacent with the idea that you could just pull a tooth if it went slightly wrong. Today, of course, things are different, and we want to keep every bit of our body if possible. When you have a healthy smile, it not only affects your health, but it also affects your view of the world.

Speaking strictly from a cosmetic viewpoint, everyone is well aware that when you have a great smile, full of teeth, you are more likely to be confident about life in general and will have a better outlook on the world. A healthy smile makes us more attractive to the rest of the world and more likely to interact with others- in a healthy fashion! Not to mention, when we feel better, the endorphins tend to flow more, and this uplifts our spirits greatly. Bottom line is that when you look good, you tend to feel good, and this means a healthier mind and body.

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In the past, it was quite common for an orthodontist to order extractions of perfectly good teeth to make the process of moving teeth and creating space with the use of braces easier. So many children are now presenting with narrow arches and crowded teeth that it made sense (somewhat) to remove the crowded teeth, thus allowing the orthodontic work to go faster and easier. But somewhere along the way a few practitioners noticed that the removal of the bicuspid teeth would often cause the upper and lower jaws to collapse backward which would lead to a collapsing of the airway as well. They also rather astutely noticed that the palate would become smaller, which made breathing more difficult as well. There are still orthodontists today who practice the method of extracting the teeth to make room and the braces go easier. However, many more are learning that there just might be better techniques.

The extractions of impacted teeth are a completely different need but also can cause the same issue. In this situation, the teeth need to be removed because 1) the lack of space in the bone means the teeth cannot erupt or 2) the tooth is growing in the wrong direction or position. In this situation, the stress placed on the jaw joint can cause the disc to be displaced and in addition, put a strain on the muscles around the jaw joint.

Of course, another method of expansion is the good old-fashioned RPE (Rapid Palatal Expander), but even this has its issues. The RPE will often just open the palate rapidly and the midline suture might not form into solid bone — it might just be a cartilaginous suture that can move around over time. This would not be very effective. The reason is on a skeletal level this instability can cause changes and distortions in the cranium. Another approach to getting some expansion is to use the ALF appliance as much as possible with the understanding that a few months with the RPE might be OK.

Another problem that is frequently seen among dentists, pulling out bicuspids, which makes the upper and lower jaws move and therefore are no longer in the same position as previously. This change can affect how the condyles (top of the jawbone) fit into the sockets and in turn, can lead to a TMJ problem. When that condyle is re-positioned after extractions, it will no longer be in the same relationship to the disc that covers it. The disc can end up displaced over time. This is what can lead to head and neck pain. So many extraction patients end up with similar problems later in life.

There are some practitioners who will actually use a palatal expander to re-open the extraction spaces to put in dental implants to ‘restore’ what was taken away. This is actually a controversial topic. As we get a bit older, the bones in the skull do indeed become more solid and if you were to try expansion a lot — like the width of a bicuspid that had been removed — it might be too much for the body to handle. Does that make sense? It might be that the expansion is just too much of a  ‘stretch’ and moving bones around might lead to more pain. This is another reason why the more conservative practitioners would use the ALF appliance to get as much gentle expansion as possible while minimizing trauma to the facial bones.

So, in general, extractions for the sake of doing braces may not be the best idea. Be sure to be careful when considering this.

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