Dr. Greg Jorgensen
(505) 891-9440
1401 Barbara Loop SE
Rio Rancho, NM 87124

The Jorgensen Orthodontics Blog

Are there alternatives to having teeth removed for braces?

Posted by Dr. Jorgensen on May 27th, 2012

OptionsNew patients and their parents usually have the four same questions for me at their first visit. Parents want to know how long treatment will take and how much it will cost. Kids want to know if they’ll have to wear headgear or have teeth removed. In this day and age, there are alternatives to headgear. Are there also alternatives to extracting teeth?

To answer this question, remember why teeth are typically removed for orthodontic treatment: First, to relieve crowding; second, to improve lip posture; third, to compensate for mismatched jaw sizes; and fourth, out of a biomechanical necessity (to allow tooth movement during treatment).

First, in cases of severe crowding, removing teeth may be unavoidable if the size and shape of the underlying bone is just not sufficient. Keeping all of the teeth in these cases would not only make patients look protrusive (teeth sticking out in front of the supporting bone), it may also cause recession (loss of gums) or dehiscence (loss of bone). With mild to moderate crowding, extraction or expansion are both possibilities. Expansion means that the size of the arch is increased by moving the teeth outward. In cases where the underlying bone is sufficient, this can be done with the braces alone. In those where the supporting bone is just too small, expanders may be used to “grow” the jaw bigger. Skeletal expansion is effective in children up until the age of about 16. After that (when the growth plates are fused), surgery may be necessary to reopen the sutures so that the roots aren’t merely pushed out of the bone.

Second, the position of the lips is influenced by the position of the underlying teeth. If a patient has good lip posture to begin with, care must be taken so that aligning the teeth via expansion doesn’t make them look protrusive. If they are crowded, this may mean the removal of teeth just to keep the lips in their original positions. In patients who already have protrusive teeth or a “full” profile, any expansion will only make the situation worse. Although it may be possible to align the teeth in these patients without removing teeth, doing so may actually make things look worse.

Third, in cases of moderate to severe overbite, there are two options for correction. One is moving the lower jaw forward (requiring jaw surgery). The other is scooting the top teeth back. In mild to moderate cases this can be achieved with rubber bands or springs. In more severe cases however, removing upper bicuspids is required to create the space necessary for greater correction. Given the choice between surgery and the removal of two upper bicuspids, most patients opt for the latter. In patients who are adamant against extractions however, jaw surgery is always an option. (Similar choices exist in patients with underbites.)

The last reason your doctor may recommend having teeth removed is to create the space and forces necessary to move your teeth during orthodontic treatment. Although it may be possible to move teeth without extractions, there are always tradeoffs. For example, one alternative to removing two lower bicuspids in a patient with a mild underbite is to using temporary anchorage devices (TADs). In these cases the orthodontist spends the first year of treatment pushing the lower molars backwards using the TADs as anchors. Once the molars are in place, he then moves the front teeth back to close the space he just created to eliminate the underbite. Had two teeth been removed at the start however, the end result would have been the same and achieved a whole year earlier. Nevertheless, TADs can be used to avoid extractions.

So is it possible to straighten your teeth without extractions? It might be. As described above, there are options. I’m reminded however of a scene from the original Jurassic Park. Dr. Ian Malcolm (played by Jeff Goldblum) looks out the window of the helicopter as they swoop in over the island for the first time. Upon seeing an actual dinosaur, he exclaims “You were so focused on ‘can we do it,’ you forgot to ask ‘should we do it.’” Although it may be possible to avoid removing teeth, it may not always be the best option when treatment time and the health of the teeth are also considered. Ask your orthodontist if any of these alternatives to extraction (expansion, surgery, or temporary anchors) are right for you.

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa in the United States. Dr. Jorgensen’s 25 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor can he select treatment plans for readers. Because he has over 25,000 readers each month, it is impossible for him respond to all questions. Please read all of the comments associated with each article as most of the questions he receives each week have been asked and answered previously. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.

117 comments so far in response to “Are there alternatives to having teeth removed for braces?”

  1. Kristy Nagy says:

    Hi, my 13 yr old son is having his braces put on tomorrow, he has a severe overbite according to his orthodontist. He wants to have two of his bottom teeth extracted. I am so worried about this. I hate to have him loose two adult teeth! He said it can be done before or after? How can you remove two teeth after and have a space on both sides? How do you fix the space? How do you extract two teeth with braces on? I don’t understand. He was very quick with explaining. Any other options besides extraction?!

    • If your son has a severe OVERBITE, he will probably have upper teeth removed. That provides the room for the front teeth to be moved back towards the palate. It is common to have the teeth removed after the braces go on. We just leave the brackets off of those two teeth and the oral surgeon works around the wire

  2. Batool says:

    Hi,
    I am getting braces. I went to two consultations. One said they can be fixed without extractions. They do not recommend extractions because if they take teeth, my face will go backwards. If I go this route I will have to get a root canal for second premolar and few fillings. I went another consultation, where the orthodontic said extractions is a must. If there is no extractions it can lead to gum thinning. Also they will be taken out second premolars since one of them need root canal and also skip fillings. I can’t decide which solution is better in the long run. Please advise.

    Thanks

    • I can’t make this decision for you unless you are my patient and you are in my treatment chair (in New Mexico!). Having said that, the first opinion you received includes some misinformation about the face going back if teeth are removed. That is not always true. The second doctor sounds more reasonable to me, but you’ll have to evaluate the two plans and decide who you trust and what is the best option for you. Good luck!

      • Batool says:

        Thanks, They literally said that I would look like an old lady If I got teeth removed. Furthermore, they said braces has nothing to do with gum thinning. It will happen regardless. They showed me my skull lined up with my lips. I don’t live in New Mexico or I would have come for an consultation. Some doctors have said both ways I will get me the same results. They will have to push teeth to front from the back about 20% and will take more effort if they remove four teeth vs they would have done IPR.

        • You’re asking the right questions. I would recommend choosing the orthodontist that you feel you identify with and trust the most and then let him or her direct your treatment. There are many ways to skin a cat, but you can only have one “cat skinner” at a time.

  3. MCR says:

    My teeth protrude out a lot and my orthodontist suggested I removed two teeth from the top and two teeth on the bottom. I already have my two wisdom tooth removed from the top and my two wisdom tooth removed from the bottom years ago. Shouldn’t those spaces be enough instead of removing 4 more teeth.

    • The space created by removing wisdom teeth is too far back to help reduce protrusion. Additionally, since there is nothing behind them in the mouth to hold onto, you can’t easily pull the front teeth back into those spaces. You need to remove teeth that are closer to the front to make any difference at all.

    • Tahesha says:

      I was told the exact same procedure for the exact same issue. Top overbite, bottom crowding requiring 2 upper and 2 lower teeth being removed before receiving braces. I too, didn’t understand why when I had all 4 wisdom teeth removed considering that would be enough space. I was a little skeptical so I put off on having the procedure done. Now seeing this I feel a bit better, knowing extracting more teeth, before braces, would be part of the required procedure for achieving a perfect smile.

  4. Jacqueline Sulton says:

    I went for a consultation for braces and was advised that I would have to have 1st premolars taken at the top and 2nd premolars removed at the bottom. But at the top, I also have to have my last back teeth extracted on both sides. If I’m getting braces for an overbite(the main reason), do I still have to have the premolars at the top removed also since as it seems space is being created by the last back teeth being removed at the top anyway? Thanks

  5. Jasmine says:

    My upper jaw is a little forward, to the extent that my mouth is closed almost all the time. I do not have wisdom teeth, My orthodontist recommended 4 teeth extractions and then braces, is it possible that i might not require extraction? I am okay if I do not get 100% perfect smile.

    • The need for extractions is determined by how much room you have (how large your jaws are). If you don’t have enough room, the teeth can’t be properly aligned without removing some. If your orthodontist has determined that you need extractions but you decline, he will not be able to give you the best results for you. In fact, you might end up with more of an overbite or even recession and bone loss if you do not follow the recommended treatment plan.

      • Jasmine says:

        Thank you for the response. I think unnecessary extractions will damage my mouth/denture in the long run, i should skip braces and wait for some technology that does not require extractions 🙂

        • I respectfully disagree with your conclusions Jasmine. Removing teeth in the right patients does not damage their mouth, it helps it. Additionally, if you have too many teeth for your mouth, you just have too many. There will never be a “technology” that changes your biology (makes your mouth bigger or your teeth smaller). Sometimes we just have to remove teeth because there simply isn’t enough room.

  6. ALEX says:

    Hello Dr. Jorgensen,

    Thank you so much for writing this blog. I’ve learned so much. My son has Class II prognathic maxilla, protrusion, mandible incisor. My naked eye only see mild crowding and slight protrusion. He is 15 years old. The first orthodontist wanted to remove 4 teeth and the second recommended to slenderize the teeth while keeping protrusion. How do you feel about the second option with Class II? I am adamant against extraction, but I would accept it if it’s the best option health-wise.

    Thank you for your help.

    • I can’t diagnose your son or help you choose a treatment plan remotely, but I can say this about slenderizing (interproximal reduction). If the teeth are perfectly straight, for every 2mm of enamel reduction, you get 1mm of protrusion reduction. That means that if your son has 2mm of enamel “shaved” between his teeth, he’ll only get 1mm of correction. That is imperceptible to the naked eye. 4mm of shaving would give you 2mm. AND, if he has any crowding at all, you probably wouldn’t see any improvement at all. If your son really needs teeth remove (14mm of tooth structure), slenderizing will not give the same results. Good luck!

  7. Ella says:

    Hi I’m 14 and my orthodontist has suggested I have 2 premolars on the top and bottom removed, so 4 premolars extracted in total. I have an overbite and my bottom teeth are a little crowded. I was wondering how they would do the treatment? Do they pull your teeth backwards? Also, there would be more room in my mouth after the extractions, so where would my wisdom teeth grow?

    • I cannot diagnose you on the Internet Ella. Generally extraction space is used to reduce crowding and create space so that teeth can be shifted (i.e. reducing the overbite). Removing bicuspids does improve the chances that you’ll be able to keep your wisdom teeth, but only from 15% to 50%.

  8. Tahesha says:

    I was told the exact same procedure for the exact same issue. Top overbite, bottom crowding requiring 2 upper and 2 lower teeth being removed before receiving braces. I too, didn’t understand why when I had all 4 wisdom teeth removed considering that would be enough space. I was a little skeptical so I put off on having the procedure done. Now seeing this I feel a bit better, knowing extracting more teeth, before braces, would be part of the required procedure for achieving a perfect smile.

  9. Jamie says:

    How are you,
    I have been wearing brace for about three years now and should get it taken out soon. However, as I look at my profile, I see some protrusion going on. Before I started my treatment, I went to a consultation, and they told me extraction was necessary because of over crowding. I went to another, and they told me extraction was not necessary. Therefore, I did not have extractions. Now the teeth are a little flared out. What can I do about it? I do not want to take out teeth now and wear braces for another year.

    • Sorry Jamie. You can’t have your cake and eat it too. Reducing protrusiveness of teeth sometimes requires extractions. You need to decide what is most important to you.

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