It seems this question is something that pops up many times over and asked by many patients. A recent systematic review of all the studies looked at the highest quality of evidence ie: RCT’s and prospective observational cohort studies and found that extractions of 4 premolar teeth in borderline cases do not worsen facial profiles, and to the contrary, where the lips are protrusive to start, provide an improvement in this appearance, as judged by laypersons. What makes this study relevant is that the authors were dentists and not orthodontists, eliminating possibility of author bias.
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What makes it rewarding for me is through conversations with the parent or carer or guardian, hearing about specific stories of our patients and their self transformation in themselves and their smiles, from their physical appearance, to mood, to day to day activities. This makes the effort and journey and their and my part all the more worthwhile.