In the accompanying schematic drawings, you can better visualize the various trade-offs of treatment decisions. The two easiest treatment decisions about extractions are when the facial profile is already very protrusive in the lips region before treatment starts, with lots of pre-treatment crowding. In these infrequent situations, it is easy to visualize that removing teeth is the best decision, because not removing teeth would only make matters worse as teeth would move even more forward as we expand the arch’s size to make room for straighter teeth. The other situation is when the profile is already very “flat” in the lips region and there is little pre-treatment crowding. In this case, extractions of teeth would definitely make matters worse because extractions would; more than likely cause the lips to move even further inward, which would be less esthetic. The trickier decisions are when the facial profile is already well balanced and we have to consider treatment effects on the profile. In very mild crowding cases with an already well-balanced facial profile, the profile changes will change very little after orthodontic treatment. In moderate crowded cases, the profile could change more than a little, especially if teeth are extracted because extractions of teeth may provide more space than we actually need to for ideal alignment. With the proper thought, communication and treatment techniques of aligning teeth and improving the bite, “surprises” are something that we are fortunately able to minimize, in any case.