When I was about 10, I had four teeth taken out by my dentist. He explained why to my mother: “Your son has inherited your teeth but, unfortunately, not your large jaws, so his adult teeth are becoming overcrowded. If we don’t remove some of his back teeth now, over the years his front ones will be pushed out and he’ll end up with a toothy grin.” I warily submitted to the gas mask over my face and awoke with my mouth streaming with blood, my tongue probing four raw chasms in my gums.

A year later, my dentist decided to remove yet another four of my new adult teeth. This time, I was ready for him and, when the hissing black rubber mask approached, I swung my right leg hard upwards. My last vision was of my foot reaching the top of its arc in my tormentor’s most vulnerable part and the poor man recoiling in doubled up horror. The anaesthetist, wisely standing to one side, pressed the mask down even more firmly.

My experience was typical of thousands of British children in the 1950s, when the prevailing orthodoxy was that tooth extraction was the only solution to overcrowded teeth. But already, there were a few doubters in the dental profession who questioned the basic premise, suspecting that extraction may adversely affect the normal development of the jaw and face (Dent Rec, Feb 1946, pp 26-35).

Since then, a growing number of orthodontists have turned their back on extraction, not least because of a reluctance to remove perfectly healthy teeth. Their solution is the obverse: if the mouth is overcrowded, don’t make space for teeth by extracting, they say expand the jaw so the teeth fit.

The early jaw expansion devices were cumbersome, but today’s so called ‘functional appliances’ are claimed to be just as easy to wear as conventional tooth braces. However, although most are designed to be worn full time, few can be used while eating.

After some 20 years of experience, there is now quite a lot of scientific evidence that jaw expansion devices will correct both overbite and ‘overjet’ (the technical term for sticking out teeth). One of the most cited examples of the effect of functional appliances is in the case of two British identical twins, Ben and Quinton. Both had overcrowded teeth, but Ben was treated by extractions followed by conventional braces while Quinton had no extractions, but wore a functional appliance.

Today, eight years on, both have normal looking teeth, but the boys

are no longer identical: Quinton’s jaws are slightly more protruded than his brother’s. Both boys say they prefer the larger jawed look but, to the casual observer, there’s not much in it aesthetically.

Functional orthodontists admit their techniques change the ‘facial profile’, but they say that extraction itself can also do the same. Removing teeth, they claim, can sometimes cause the jaw to contract. The example they often use is Princess Anne. She had extractions to correct overcrowding, making her chin recede and her nose appear larger, according to functional orthodontists.

Their charges against extraction don’t stop there. There is a whole litany of problems that removing teeth is meant to cause: headaches, trigeminal neuralgia, tinnitus, sinusitis, headaches, jaw clicking, and neck and shoulder problems. Many of these are believed to be related to the temporomandibular joint (TMJ; the connection between the skull and the jaw), which may be unduly stressed when the teeth don’t meet together properly. In a recent publicity campaign in Britain, functional orthodontists brought patients before the television cameras with harrowing tales of TMJ-related problems after extraction (‘Despatches’, Channel Four, November 1999).

But, when you look for the scientific evidence for all the commotion, it isn’t there.

In the overwhelming majority of clinical studies, extraction was found to cause no more TMJ problems than any other treatment (Am J Orthod Dentofacial Orthop, 1991; 100: 110-5; Am J Orthod Dentofacial Orthop, 1992; 101: 4-20; Angle Orthod, 1993; 63: 257- 72; Angle Orthod, 1995; 65: 175-86).

And neither does the evidence concerning changes in the look of the face favour an exclusively functional approach. A number of studies show that functional orthodontics will alter the facial profile by pushing out the jaws and enlarging the lips; such changes are generally considered to be an aesthetic improvement, although these judgements must be subjective, particularly when you realise that some of the studies may have been conducted by the proponents (Eur J Orthod, 1989; 11: 243-53; Am J Orthod Dentofacial Orthop, 1996; 109: 38-49).

Conversely, do extractions cause the ‘dished in’ appearance their critics claim? The evidence is equivocal, with some studies showing a deleterious effect (Br J Orthod, 1997; 24: 25-34) and others, little or none (Angle Orthod, 1998; 68: 539-46; Am J Orthod Dentofacial Orthop, 1995; 107: 28-37), and still others showing aesthetic improvement (Am J Orthod Dento-facial Orthop, 1998; 114: 265-76). Indeed, when, people were asked if they liked their appearance years after their extractions, all were satisfied (Am J Orthod Dentofacial Orthop, 1992; 102: 1-14b).

Perhaps it’s all such a confusing picture because our teeth and mouths are different, and dentists find it difficult to predict exactly how they will grow (Am J Orthod, 1981; 80: 349-65). As orthodontist R.D. James candidly admitted: “Evaluation of facial profiles and balance is a constant continuous study and learning process” (Am J Orthod Dentofacial Orthop, 1998; 114: 265-76).

Of course, an important consideration is the practice of removing healthy adult teeth when so many other dental practices are proving to be hazardous.

So, should I have kicked the anaesthetist as well as the dentist? The simple answer is I don’t know. But when I get my nine year old daughter’s overcrowded teeth fixed, I shall avoid fanatical tooth extractors and expanders alike.

!ATony Edwards

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Written by What Doctors Don't Tell You

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