Dr. Greg Jorgensen
(505) 891-9440
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.

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

  1. moi says:

    What can you tell me about jeferson cephalometric analysis ….in the final result …can make a person look better(profile)…vs the classical cephalometric analysis?…tks….look at this example http://jeffersondental.com/functional-orthodontics.html …….http://www.youtube.com/watch?v=eTNvAjAOht8…..?

    • Cephalometric analysis of any type is just one tool that a dentist uses to evaluate the jaw structure of a patient. No particular analysis will make a patients profile better or worse. The website states that the doctors in this practice are primary care providers (general dentists) and not orthodontic specialists. The “functional orthodontics” they are describing is nothing new. They can expand arches, tip upper incisors back and lower incisor forward, and change the direction of growth (open the bite). They do NOT induce extra growth as claimed by some practitioners. Orthodontists use functional appliances when appropriate but understand their limitations. Being a specialist myself, I would encourage you to seek a consultation with a specialist who has between 4,000 and 6,000 hours of university training in diagnosing, treatment planning, and correcting malocclusions rather that a primary care provider who had a class or two in dental school and some weekend courses after graduation. I would never let my primary care physician do Lasik on my eyes!

  2. Julie says:

    After my daughters first consultation(she is 11) the orthodontist has said that he plans to use a functional appliance to align the jaw (class ii malocclusion div 1 and deep bite) and then she will most certainly need teeth extraction followed by braces. This sounded ok in the office but then once we were given a copy of the treatment plan he has stated that she will almost certainly need back molars extracted and will accept single molar occlusion only. Does this mean that he plans to leave her with only a single set of molars on the top and bottom?? This sounds abit drastic. One of her 12year old molars has not come through and is impacted on xray. She does have big teeth and there is crowding on the top however none of her teeth are overlapping. Is it common to extract back molars? From my quick google search everything suggests premolars are extracted. I have asked our general dentist and he advised to get a 2nd opinion. Any helpful info will be appreciated, thanks.

    • There are limits to how many teeth will fit in a given mouth. If there is crowding in the back, the molars may be impacted. If there is crowding in the front there may be crowding (overlapping) or protrusive teeth. A functional appliance will help the deep bite, but any overbite correction you see will probably be due to shifting the teeth within the bone. Bicuspids are the teeth most commonly removed for orthodontic treatment. Removing molars is sometimes necessary, but I have done it a few times and only because I had no other options. Before your daughter has any molars removed, I would request a very specific explanation of why it needs to be done and why it is a better option than all of the others. Good luck!

  3. Gina Grigsby says:

    My orthodontist is recommending upper and lower tads to lift he gum line so that she does not show a lot of gum when she smiles. I never noticed it before and she has beautiful smile. They would put them on the 2nd year of braces. She will then need to wear braces for 3 years. Is this a cosmetic proceedure and is it really necessary? It is also costly.

    • Excessive gingival display (gummy smile) really is just a cosmetic problem UNLESS the underlying problem is a long face. When the face is too long, closing the lips is strained leading to mouth breathing, excessive plaque accumulation, etc. If it is only for looks it is cosmetic. If it is for lip closure (which usually requires surgery), then it is functional also.

  4. Matt says:

    Hi there,

    my concern relates to thinness / sunken cheeks post orthodontic treatment.I am now at the stage of wearing a retainer only at night after 5 – 6 years of brace-wearing; first I had two teeth out on the upper teir, then wore a removable plate for a year – possibly more – then fixed braces for the rest. Quite a long time and a slow process.

    I only had work done on my top teir of teeth, as the bottom set, though not great, didn’t bother me nearly as much. With wisdome teeth already out and two more as part of the orthodontic work, I now have a total of 12 teeth in the top teir. Should this be enough teeth to prevent any face sinking? When I look at some pictures now, I feel I see my cheekbones more pointy and my cheeks more inward. I can’t be certain how much of this is my own paranoia and how much may be true, but it is causing me so, so much distress. My face, naturally due to the way I aged into adult-hood became thinner and more ‘cheek-boney’ but looking at more recent pictures I can’t help but consider the possibility of a shift to a look that is too thin/sunken/gaunt.

    I guess, if anything, I am seeking some kind of reassurance based on the criteria of my situation:

    Began at 28 years old
    Two extractions from upper arch totalling 4 as wisdoms already out
    Removable plate 1 to 2 years
    Fixed brace – with pulling – 3 to 4 years
    I am now 34 years of age

    I just wondered what your opinion on this would be; the likelihood, or otherwise, of face-sinking, given the above criteria. My orthodontist had said something about over-crowding, but I am left with some small gaps between teeth: mainly back right not really visible; though a small gap visible from one side just before the rest of the teeth are hidden (when smiling)

    I think one of the teeth I had removed may have been a moler

    I should add, when I looked at pre-brace pictures – having seen some post-brace pictures that worried me – I did discover that I always did have cheekbones and, therefore, indents of a kind, I just fear they are now more so; perhaps even a little extreme in appearance

    Though I ask for reassurance, the facts-of-the-matter or, at least, the fact of your opinion are what matter to me more/most

    Many thanks for reading and apologies for the rather garbled nature of this email; it most certainly reflects my ongoing concerns, worries and fears: my brace had been off over a year now, and still I can’t let all these worries go

    Thank you very much again,

    • Matt, everyone’s facial structure changes with age, weight, etc. There is no way that removing two teeth could possibly cause all of the changes you are describing. Relax and like the rest of us, just accept that our bodies change with age!

  5. Emma says:

    Ive seen two orthodontists so far and one recommends removing my lower second pre molar teeth. But the other recommends that i remove those as well as the upper pre molar teeth. My front teeth seem to be slightly more forward than they should.
    Is it necessary to remove teeth from the top, if two teeth are removed from the bottom?
    My top is near perfect, however the bottom has mild crowding. Additionally bite alignment is ideal.

    18 yrs of age.

    • I cannot diagnose cases over the Internet. Removing teeth is done to reduce crowding and to correct bites. Your doctors need to explain their rationale for recommending these extractions and you need to be comfortable with their explanations before you proceed.

  6. Nykyra says:

    i have really confronting protrusive front teeth (top and bottom) with crowding up the top in the front. My orthodontists as recommended i have teeth removed from both upper and lower aches to move my teeth back as he says i don’t have enough room but I’m worried about my lip sinking in.

    • If your front teeth are already protrusive AND are crowded, there is very little chance that removing teeth in the upper will cause your lips to move backwards. If you have an overbite and not much crowding in the lower, you may only need two removed from the top. Ask your orthodontist if this is an option for you.

  7. ranel says:

    Hello Doctor Jorgensen. I am currently wearing braces, and my upper pre molars were already extracted. I asked my ortho why he only removed the upper pre molars, he explained that I have a small chin and and removing my lower pre molars would make my chin even look smaller. Just a question, since my lower front teeth is somewhat forwarded, it makes my lower lip look pouted. Any suggestions or ideas regarding my case? Thank you and more power!

    • Your orthodontist is probably right. What he is doing is compensating for your smaller lower jaw by moving the top teeth back to match the it. Ideally a patient with a small lower jaw would have it surgically repositioned to match the normal upper jaw, but this is a major surgery that is expensive, invasive, and more than a lot of patients are willing to go through to reduce their overbite. Removing your lower bicuspids too may move the lower teeth back, but it may make correction of your overbite impossible without surgery.

  8. Erik K. says:

    Hello Dr.Jorgensen,

    First off, thank you for your article called “Why does my orthodontist only want to remove two teeth in the upper arch?”. It did help us understand why we may be better off removing only 2 teeth (as opposed to 4) in our 16-year-old daughter’s case. She’s been wearing braces for the last 1.5 years and her upper teeth are now lined up properly. She does have overcrowding with her bottom teeth though. Her ortho recommended to remove 2 teeth from the bottom and 2 teeth from the top. We went for the second opinion and the other ortho recommended to remove only 2 bottom teeth.

    We still don’t feel comfortable with removing healthy teeth. Would you please tell us what other alternative we could have?

    Thank you very much.

    • Sometimes there is not enough room for “healthy teeth.” It is not a question of whether or not the teeth are healthy, it is a question of whether or not you have room for them. Please understand that keeping all of your healthy teeth and aligning them when there is not enough bone can cause unhealthy problems like bone loss and recession. The reason orthodontists have so much training is to know when removing teeth is appropriate.

  9. Osuni says:

    Hi Dr. Jorgensen,
    Thanks so much for your thoughtful responses. I have a question. I am 40 years old, should have started orthodontic treatment early but did not. I grew up in a part of the world where these things are none existent. I have always been concerned about my looks. I have larger lips and have an open bite. My lips protrude. Looking at my x-rays, it looks obvious that both my front teeth, both upper and lower push out severely. I therefore breath through my mouth sometimes and of course I also have a problem closing my mouth. I do it consciously. That obviously contributes to my open bite situation. The problem I have had is that I have heard all sorts of different opinions from orthodontists. A majority have mentioned that an open bite can only be closed through surgery. My most recent one (I am seriously thinking of going with him), has told me that surgery isn’t necessary and that he is going to remove my two pre-molars and that should in fact be enough to pull back my teeth. He is the expert but I just wanted a second opinion. I have been meant to believe that I do have a jaw problem and that surgery is paramount to any successful plan. Would you be of the same opinion that an open bite can only be closed by surgery? If I did remove the molars and during treatment we do realize that surgery is needed, would this be in any way tricky? I am prepared to be told that surgery is needed later on, I would be fine with that but I just don’t want to be told later that the removal of the teeth would have some sort of adverse effect. I have never been able to smile freely all my life given my teeth are the way they are but if an open bite can be closed by removal of teeth, by all means this is welcome but just wondering if it is also true that no surgery will be needed. Thanks in advance!

    • Braces can move teeth. Surgery moves jaws. If you have a mild to moderate problem, removing teeth can allow tooth movements that can camouflage the jaw problems, not correct them. If your openbite is moderate to severe, you may need to have the jaws moved. This is a case for a qualified orthodontic specialist with lots of experience in surgical orthodontic treatment.

  10. Rob Austin says:

    My 11 year old daughter is about to start orthodontic treatment. She has an extreme overjet/bite (trying to decide which term is right). Her Ortho wants to extract the #5 and #12 and then bring all the teeth back to close the gap. I see very mixed opinions on this upon researching further. Thanks for your opinion on this.

    • Overjet describes the horizontal relationship of the upper and lower teeth (how far they stick out) and Overbite describes the depth of the bite (vertical). The ultimate way to correct overjet is to keep all the teeth and surgically move the lower jaw forward. Having said that, not everyone wants or needs surgery. Therefore removing two upper teeth is an acceptable alternative in most patients. The best sports car on the market may be the Porsche, but the Mustang is a great alternative.

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