Severe dental crowding is one of the main clinical indications for premolar extraction in orthodontic treatment.
This strategy aims to create space for proper alignment of teeth and to improve both function and facial aesthetics.
Below is a review of the most relevant scientific findings from the last seven years regarding the use of premolar extractions in orthodontics.
When Are Premolar Extractions Indicated?
Premolar extractions—particularly first premolars—are commonly recommended in Class I malocclusion cases with severe crowding, bimaxillary protrusion, or significant dentoalveolar discrepancies.
Their strategic position allows for efficient space closure and anterior teeth retraction, often enhancing the facial profile.
In contrast, second premolars are typically removed in cases with milder crowding or when anchorage control is a key concern.
► DENTAL BOOK: Orthodontics - Diagnosis and Management of Malocclusion and Dentofacial Deformities - Om Prakash Kharbanda
Early vs Late Extraction Timing
A systematic review comparing early extractions (in the mixed dentition) to late extractions (in permanent dentition) found both approaches effective for crowding correction.
However, early extractions were associated with shorter treatment duration and a lower risk of relapse.
Long-Term Effects on Facial Structure
A 50-year longitudinal study analyzed patients with Class I malocclusion treated exclusively with premolar extractions and no subsequent orthodontics.
The findings showed no significant differences in sagittal skeletal relationships or incisor inclination compared to untreated controls, indicating that extractions alone do not negatively impact long-term facial structure.
Impact on Airway Dimensions
Recent imaging studies indicate that premolar extraction followed by orthodontic treatment can actually increase upper airway volume in patients with severe crowding.
This challenges previous assumptions that extractions may compromise airway patency.
What Do Systematic Reviews Say?
A comprehensive review published in 2024 concluded that premolar extractions do not adversely affect periodontal health or long-term orthodontic stability.
Moreover, they can be particularly effective for aligning crowded arches without compromising facial aesthetics.
Conclusion
Premolar extraction remains a valuable technique in the treatment of severe crowding malocclusion.
Recent evidence confirms its effectiveness and long-term safety, especially when planned carefully and integrated into a comprehensive orthodontic treatment strategy.
Individualized evaluation remains key in deciding the appropriate approach for each patient.
References
- Al-Taai N, Persson M, Ransjö M, et al. Dentoskeletal and soft tissue changes after treatment of crowding with premolar extractions: a 50-year follow-up. Eur J Orthod. 2023;45(1):79–87.
- Persson M, Al-Taai N, Pihlgren K, Westerlund A. Early extractions of premolars reduce age-related crowding of lower incisors: 50 years of follow-up. Clin Oral Investig. 2022;26(6):4525–4535.
- Zhang K, Li J, Yu L, et al. Extraction camouflage treatment of a skeletal Class III malocclusion with severe anterior crowding by miniscrews and driftodontics in the mandibular dentition. Eur J Med Res. 2025;30(1):48.
- Tooth extractions in Orthodontics: first or second premolars? Dental Press J Orthod. 2019;24(2):67–73.
- Early vs late orthodontic treatment of tooth crowding by first premolar extractions: a systematic review. PubMed. 2014;25208231.
- Extraction of premolars in orthodontic treatment does not negatively affect facial aesthetics: a systematic review. Eur J Orthod. 2024;47(2):cjaf012.
