To compare four first premolar extraction and nonextraction treatment effects on intra-arch width, profile, treatment duration, occlusal outcomes, smile aesthetics and stability.

Materials and Methods

An electronic search of the literature to June 2, 2023 was conducted using health science databases, with additional search of gray literature, unpublished material, and hand searching, for studies reporting nonsurgical patients with fixed appliances regarding sixteen sub-outcomes. Data extraction used customized forms, quality assessed with ROBINS-I (Risk Of Bias In Non-randomized Studies—of Interventions) and Cochrane RoB 2 (risk-of-bias) tool. GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessed certainty of evidence.


Thirty (29 retrospective studies, 1 randomized controlled trial) studies were included. Random-effect meta-analysis (95% CI) demonstrated maxillary (MD: −2.03 mm; [−2.97, −1.09]; P < .0001) and mandibular inter-first molar width decrease (MD: −2.00 mm; [−2.71, −1.30]; P < .00001) with four first premolar extraction; mandibular intercanine width increase (MD: 0.68 mm; [0.36, 0.99]; P < .0001) and shorter treatment duration (MD: 0.36 years; [0.10, 0.62]; P = .007) in the nonextraction group. Narrative synthesis included three and five studies for upper and lower lip-E plane, respectively. For American Board of Orthodontics Objective Grading System and maxillary/mandibular anterior alignment (Little’s irregularity index), each included two studies with inconclusive evidence. There were no eligible studies for UK Peer Assessment Rating (PAR) score. Class I subgroup/sensitivity analyses favored the same results. Prediction interval indicated no significant difference for all outcomes.


Four first premolar extraction results in maxillary and mandibular inter-first molar width decrease and retraction of upper/lower lips. Nonextraction treatment results in mandibular intercanine width increase and shorter treatment duration. There was no significant difference between the two groups regarding maxillary intercanine width, US PAR score, and posttreatment smile esthetics. Further high-quality focused research is recommended.

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Author notes


Private Practice, Cairo, Egypt; and former postgraduate student, Orthodontics, School of Dentistry, University of Dundee, Dundee, United Kingdom.


Clinical Lecturer and Honorary Consultant in Orthodontics, School of Dentistry, University of Dundee, Dundee, United Kingdom.


 Honorary Professor of Orthodontics, School of Dentistry, University of Dundee, Dundee; and Consultant in Orthodontics, NHS Fife, United Kingdom.

Supplementary data