In the golden age of orthodontics, the 60's and 70's (when all the baby boomers became teenagers and orthodontics became more mainstream), most kids who had any crooked teeth had four premolars removed, one in each quadrant of the mouth. In recent years, most cases of minor and moderate crowding are treated without removal of permanent teeth, using newer techniques such as expansion and tooth size reduction to gain the space necessary to align the teeth, However, some cases of moderate, and certainly severe crowding are best treated by removal of four permanent teeth.

Whenever severe crowding is present, attempts to align the teeth will invariably lead to flaring out of the teeth, If the teeth are already flared forward, further flaring would lead to a protrusive profile. Some orthodontists tout themselves on the claim that they never resort to removing teeth, but their results often demonstrate facial disharmony and lead to results which are more prone to relapse after treatment. Most top orthodontists are willing to concede that some cases are better served by an extraction approach.

If your teeth are crowded, but leaning inward, in what looks like a narrower, tighter arc, and your profile is flat to concave, then expansion and flaring may lead to better lip support, and a non-extraction approach attempted. One quick, non-scientific guide used by orthodontists to quickly gauge a profile, is by asking the patient to gently close their lips until they touch. If the teeth are out too much, the chin will wrinkle. This is called lip incompetence. A cephalometric radiograph is used as a more scientific tool to measure your jaw position and tooth angle.

Your parents or grandparents may have lost many teeth as they aged. In today's more enlightened climate, most people receive more preventive dental care, and practice better oral hygiene. Natural loss of permanent teeth through aging is very unlikely, and therefore, removal of teeth for orthodontics really has few negative ramifications. If the case is properly diagnosed, the extraction spaces are totally closed, and the resulting profile is harmonious.

Invisalign is currently accepting premolar extraction cases, but despite the hundreds of cases Invisalign cases treated in this office, no such cases have been attempted with Invisalign. However, we often combine Invisalign with regular braces, lessening the overall time with braces. Keep in mind that for certain types of non-extraction cases, Invisalign is equal or even more effective than regular braces. I do not think that even Invisalign is willing to concede that in most cases of four premolar extraction, Invisalign alone is more efficient than regular braces.

Dr. Goodman is a Certified Invisalign® Provider