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.

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

  1. Mali Sawaria says:

    My sister had an orthodontic treatment in which her two premolar upper teeth were extracted to make the space (as she had overcrowded teeth in the upper jaw line, the lower one has no overcrowding)…As per doctor’s suggestion, her two premolars from lower jawwline shall also be removed in order to have a proper matching jawline and teeth cycle. I am confused bcoz if the lower jawline is fine, not at all overcrowded, then is ‘tooth extraction’ becomes mandatory to maintain teeth cycle that my doctor talked about..pls guide.. I mean is it important to remove the premolars from lower jawline if not required..

    • If your sister has jaws that are the same size and the bite is good, four teeth should be removed. If she has an overbite and the lower jaw is small, it is usually preferable to not remove bottom teeth. There are exceptions, but removing four teeth when their is an overbite makes correction much more difficult.

  2. Taylor says:

    Hi I went to two orthodontists and they both said completely different things when it came to teeth extractions. The first one said they only wanted to remove one tooth from my upper jaw and the other wanted to remove four (two top, two bottom). Is it a common practice to just remove one tooth?

    • It is much more common to remove four than one. I would present both treatment options to each orthodontist and have them explain why their plan is different. Choose the one that makes the most sense (and make sure they are both equally educated and have the same experience).

  3. Jenny says:

    My son does not have permanent adult teeth K, T. His orthodontist originally suggested to remove baby teeth A, J, K, T, and remove adult A, J teeth when they come out, but he now suggested to remove 4 baby teeth and adjacent adult teeth 5 and 12 to make extraction all at once. This means in the future, his adult A,J teeth will touch bottom adult teeth 28 and 21. Will it cause problem on biting? Thanks Dr Jorgensen.

    • There are as many successful treatment plans as there are kids. It sounds like your orthodontist has a plan. Make sure it makes sense to you and work together on the plan so that it will work out in the end. Remember that your son already has a compromised situation because of the missing teeth. The goal is to find the best solution for him.

  4. David says:

    My daughter has had braces for almost a year. The main issue was the top front teeth (which are relatively larger) were also protruding a bit and a little crooked. After 5 months, lower braces were added. All her teeth now look straight and I know she will need the braces or a retainer for another year while they set into place. The ortho now wishes to remove the rear two top molars as there is a slight but definite overbite. My concern is that the lower rear molars will have no teeth to grind against. I had upper wisdom teeth removed while lower ones came in straight and now need my lower wisdom teeth removed as keeping them clean and plaque free at the back is problematic. My daughters wisdom teeth dont look great (she is 14) and I do not want my daughter to end up without molars! Comments?

    • The removal of two upper second molars is less common today than it has been in years past. The theory is that you can more easily move the other top teeth back to reduce the overbite and then allow the upper wisdom teeth to drop into place where they would have been. The drawback is that you are taking a chance with the wisdom teeth. There is no guarantee they will be shaped correctly, come in to the right place, or even come in at all. I’m not a fan of this approach because of the uncertainty, but I’m not saying it can’t work.

  5. avinash says:

    Hi sir, one year ago had undergone a upper left impacted canine surgery for which my orthodontist removed my upper premolar, now the canine is there on dental arch and my orthodontic treat me is almost done and my concern is that does it going to affect my facial aesthetic ?

  6. Emma says:

    I’ve had braces for 4 years to fix crowding and an impacted canine. My orthodonist has now asked me to remove my rear molars to fix a slight overbite which has become worse since treatment (he says he’s 95% sure my upper wisdom teeth will come down, however my dentist says she doesn’t think they are likely to, and another orthodonist says they are unpredictable). I’m concerned, because these teeth are large and perfectly healthy. My questions are: If I want to slightly improve my overbite without extractions, is this possible? If extractions are my only solution to reduce the overbite, I’m wondering if it’s better to remove premolars or rear molars? Or will there be no difference in terms of appearance/long-term health of teeth? Thank you.

    • I share the opinion of the orthodontist that said removing permanent second molars is unpredictable. That is risky and not common way of fixing overjet in adult patients. There are many ways of reducing overjet in adult patients, but only a local orthodontist with you and some diagnostic records in his hands can tell you what is best for you. I would not remove second molars in my own family if that is helpful.

  7. Phan Mai says:

    Hi Dr Jorgensen,

    I understand from here that in case the two jaws are of the same size and the bite is good, four teeth should be removed (both upper and lower) in order to correct overcrowding and protrusion. My daughter has the same situation. She has large front teeth protruded. But the teeth of the lower is very OK, small and nice enough for the size of the jaw and straight, not overcrowded at all. I don’t understand one thing. If removing upper teeth will make space to push the large teeth inward in straight position, what will compensate for the space in the lower? Can removing lower teeth like this can lead to smaller jaw than the upper because how can you make the lower teeth as big as the upper?
    Maybe it’s complicated but pls tell me. Thank you so so much.

    • If you have an overbite and remove teeth from both jaws, you’ll still have an overbite after all of the spaces are closed unless another force system is added (like springs or rubber bands).

  8. Olivia says:

    Hi Dr Jorgensen

    I have previously has braces and worn a twin block to correct an overbite/overjet, and did not have any teeth extracted. Back then my orthodontist advised against having 4 teeth removed due to facial profile. As my front teeth are still protrusive and my bottom teeth have shifted, I consulted an orthodontist, who advised the best options would be to have four premolars removed followed by jaw surgery or to have two upper premolars removed. The first option seems too drastic, however I am wondering whether there would be any negative facial changes with the second. Any thoughts would be appreciated

    • Every patient is different, so I can’t comment on you specifically. I will say that I’ve used this technique with hundreds of patients where it was appropriate and have had no adverse effects or complaints

  9. Susan Coyne says:

    My daughter is 11 and has a moderate to severe overbite. She has braces at nine to minimize the jaw discrepancy, on the top teeth only. She also had headgear. They were on for 1 year when we moved to Florida. At that time they took the braces off as phase 1 was completed. While her jaw seems to have been corrected (she does not have the flat prolapsed profile anymore) she still has the overbite. (7-10mm). We have had 3 consults, all different. The first was that braces alone would not correct the jaw and that she would probably need surgery as an adult after traditional braces. The second orthodontist said she would need traditional braces, along with a Herbst applisnce. Not happy with those, we went for a third consult. This doctor wants to remove 2 1st bicuspids to make room to push the teeth back and down. The thought of a 4th consult is overwhelming for both my daughter and me. I appreciate your input. Thank you!

    • You have to choose the orthodontist that you feel most comfortable with. I think a 4th opinion would just confuse you even more. Pick one and put your trust in his training and expertise.

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