Dr. Greg Jorgensen
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1401 Barbara Loop SE
Rio Rancho, NM 87124

The Jorgensen Orthodontics Blog

Why does my orthodontist only want to remove two teeth in the upper arch?

Posted by Dr. Jorgensen on July 23rd, 2013

Overbite girlThe articles that attract the most comments on my blog are those addressing the removal of permanent teeth (also called pulling or extracting teeth). I sympathize with parents and patients who are worried about having perfectly healthy teeth extracted for orthodontic purposes. The explanations I’ve provided in other articles have helped many patients to understand why this can’t be avoided in many cases (see Are There Alternatives to Having Teeth Removed for Orthodontic Treatment?, Will Having Teeth Removed Ruin My Face?, and Why Do I Need Teeth Removed for My Braces?). Today’s blog post addresses a specific extraction pattern that I’ve been asked about numerous times: removing two teeth in the upper arch only.

There are three main reasons that I remove permanent teeth during orthodontic treatment: crowding, protrusion, and camouflage of a jaw-size discrepancy. As much as I would like to avoid removing teeth, there are some mouths that are just too small for all of the teeth. In these cases, NOT pulling teeth makes the smile less attractive, less healthy, and less stable. Protrusive teeth are just crowded teeth that have been flared out away from the bone. If they were to be moved back over the bone where they should be (without removing any), they would overlap (be crowded). To relieve crowding and protrusion I sometimes need for your dentist to remove some permanent teeth. The space created is then closed to eliminate the crowding or reduce the protrusion. Done correctly, no one but you and your dental team will ever know that you’ve had teeth removed.

When the upper and lower jaws are genetically different sizes, the only way to truly make them match is surgical repositioning (orthognathic surgery). Surgery is required when patients have a severe discrepancy or want a specific cosmetic improvement (i.e. a bigger chin). Most patients however are fine with just having their “overbite” corrected without the surgery if the final result is attractive, healthy, and stable. Removing teeth in only one arch is the most common way to camouflage a jaw-size discrepancy. About two-thirds of my patients have an overbite. Mild to moderate overbites can be corrected with rubber bands or springs. In those with more moderate to severe problems, extracting teeth or surgically moving the jaws is necessary.

If a patient has a small lower jaw, removing two teeth in the upper arch allows the orthodontist to move the upper front teeth back to match the position of the lower teeth without surgery. This allows us to hide or camouflage your small lower jaw. The same thing can be done in some underbites. If conditions are just right, two teeth may be removed from the lower arch to allow the lower front teeth to be moved backwards correcting the underbite. If teeth were removed in both the upper and lower arches in overbite and underbite patients, the upper and lower front teeth would move together and no improvement would be accomplished. Please understand there are many variables that your orthodontist must take into account when determining if camouflage treatment is appropriate for you. This explanation is an over simplification, but you get the idea.

So if your orthodontist suggests removing teeth from only your upper or lower arch, chances are that you have a jaw-size discrepancy that he is trying to improve for you. I’ve been using this extraction pattern for over 20 years and in the right patients the results are amazing. Remember to ask your orthodontist about any extraction pattern that doesn’t make sense to you. The best patients are the most informed patients.

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.

100 comments so far in response to “Why does my orthodontist only want to remove two teeth in the upper arch?”

  1. Cristina says:

    hello, i’m 17 years old and i have an underbite which has developed within the last two years, none of my family have this problem and when i was 15 i had one canine tooth from my upper set of teeth removed because i had an overbite and crowding in order to straighten my teeth with braces. I then had my braces fixed and the gap started to close, however i noticed my face shape changing, my upper lip looked thinner and my face started to look longer, the whole structure of my face has now changed and now my upper teeth do not align with my bottom teeth. After talking to my orthodontist he suggested that jaw surgery would be the best way to fix my underbite, i am very confused as to why this has happened and i dont like the idea of having to go through surgery, is there any other way of fixing this problem?

    • I’m sorry Cristina. This sounds very complex and I could not begin to explain what is going on without full diagnostic records and you in my chair. Please seek out a second opinion in your area.

  2. rachita kashyap says:

    Hello, I’m 28 years old and i have a overbite which wasn’t corrected even after my treatment. I underwent orthodontic treatment 8 years back and since then i was wearing permanent retainer. Few months back i guess accidently i broke a link of my retainer with the front tooth and i didn’t consulted a doctor as it had been almost 5 years since i was wearing retainers. I was advised by my dentist to keep the retainers for minimum 2 years. Now a large gap (sort of a diastema) has come up and one of the tooth has started to overlap the other side tooth. Recently i consulted another dentist (as my previous dentist has left the country) and she is suggesting the extraction of my premolars on the upper jaw. Already i have a small face according to my height which is very common in my family and now I’m concerned that extracting the teeth and moving the upper jaw teeth backwards may lead to further shortening of my face. Please suggest what should i do.

    • I can’t diagnose your case for you, but I can say that you had orthodontic treatment before where teeth were not removed and you still had an overbite afterwards. My guess is that if you have the same treatment redone the same way, you’ll end up with the same result. Maybe you should have had teeth removed the first time. Orthodontists usually remove teeth only when it is necessary. I doubt the one you saw would recommend it if it was going to make you look worse afterwards.

  3. Juan Paolo Estrada says:

    Hello iam 16 years old right now and i have a severe case 3 UNDERBITE. ive been wearing my braces for 3 years now and my underbite is still not corrected. i’ve already extracted two lower front teeth and my teeth style is okay and good but the underbite is still not corrected and m dentist told me. that i have to extract two wisdom tooth on the back of my teeth. they told me its for the process of correcting my underbite. i dont know if its necessary so i’m asking for your SECOND OPINION on this matter so what should i do. i have a LONG, BIG CHIN, my LOWER LIPS are in FRONT. i cant PROPERLY SMILE. I have DIFFICULTY IN SPEAKING.

    • It is highly doubtful that removing wisdom teeth will do anything to correct your Class III, underbite condition. If you’ve already had two bicuspids removed and three years of treatment without success, the only remaining remedy may be surgery. I would discuss this with your orthodontist (by the way, you may need your wisdom teeth removed for other reasons, but it won’t correct your underbite)

  4. ariana says:

    hello doc , i have slight (4mm) vertical maxillary excess. i am avoiding surgery at all cost. my doctor said to contour teeth and pull the teeth back with braces and correct my gummy smile. will it help to correct my slight protrusion or have to remove 4 teeths

    • This is a tricky question without having you in my chair with diagnostic records. Pulling the teeth back does NOT usually help vertical excess however. Most times retracting the teeth makes MORE gum tissue show. If you have a gummy smile your options include jaw surgery, gum surgery, or orthodontic intrusion (with or without TADS). The amount and appropriateness of gingival display reduction that can be achieved using these techniques is different for every patient. Removing teeth in my experience increases the amount of gingival display.

  5. Shankli vatsa says:

    My gap between the teeth due to extraction isn’t filling fast.there is still some space left. It’s been 14 month now since I have my braces. Is it the thing to worry about.

    • It is rare that an extraction space would take longer than a year to close. I would discuss your concerns with your orthodontist to try and figure out why it is taking so long.

  6. Beth says:

    Hi Dr. Jorgensen. My husband, age 47, had a severe underbite. An orthodontist told him he didn’t need surgery and said he could correct it with braces only. He pulled 4 teeth from his lower jaw and his wisdom teeth. Then he angled his lower teeth back very significantly. Now my husband has VERY noticeable speech problems. When we asked the ortho about it, he said he didn’t notice any problem and brushed us off. I feel he was negligent as now we have to pay for adult speech therapy. What are your thoughts? Thank you.

    • I would get a second opinion. YOU and your husband are the final judges of whether or not the treatment outcome is acceptable. The best treatment may be to replace two of the teeth (so they are not all tipped back) and have the surgery he should have had in the first place. Your husband only has one set of teeth. Do whatever you have to to get this right. Good luck!

  7. Celeste says:

    Our orthodontist is requesting that my daughter’s overbite (overjet?) be corrected by extracting the maxillary right 2nd bicuspid (#4) and the maxillary left 1st bicuspid (#12), and he will use her current braces and bands to close the gap and make the overbite (jet?) less noticeable. She’s 14 and has stopped growing, for the most part. He feels this will be more effective than the mara device. I think I’m ok with the plan, but is it odd that the removal of teeth is not the same on each side? It’s not even, and this concerns us. If that’s not entirely abnormal, I’d feel better hearing that from another orthodontist! Thanks.

  8. Rachel says:

    My lower jaw does not align at all with my upper jaw. So much so that I have popping in the jaw joints, and my lower lip is visibly behind my upper lip. An orthodontist mentioned the option of pulling one of my upper teeth to make them align. He didn’t recommend it, but it sounds like it would be a lot cheaper. Where would I go to get this kind of surgery and do you think it would fix my problem? Thank you!

    • I cannot diagnose you on the Internet, but I’ll offer this. First, overbites don’t cause your jaws to pop. Second, having teeth removed can help reduce an overbite, but it doesn’t change the jaw alignment at all. It works by allowing the upper front teeth to be moved back. The underlying bone stays in the same place

  9. Miles says:

    What is the difference between 1st & 2nd premolar extractions for braces?

    • Choosing which teeth to remove depends upon many factors including 1) amount of retraction needed, 2) biomenchanics/anchorage, 3) condition, shape, size of the bicuspids, etc. An orthodontist looks as the entire picture and determines if there are bicuspids that are in bad condition or funny shaped. If not, then he looks as where he wants the front teeth to end up. That also takes into consideration the amount of crowding and the amount of tooth movement desired. Lastly, he will decide which teeth need to move and which need to stay in place. Where space is created affects that. As you can see, it can be a complicated decision.

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