Is It Possible to Treat All Orthodontic Patients without Removing Teeth?

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No subject has attracted more attention on my blog than the removal of permanent teeth. A few skeptical readers have suggested that orthodontists remove teeth to make more money, because they are uneducated or old fashioned, or even that they just don’t care about the looks of their patients after treatment. I would like to to address these three concerns in detail.

Orhodontists do not remove teeth so they can charge more
One commentor on another blog suggested that orthodontists recommend the removal of teeth to make more money. The truth is that extraction treatment is more difficult, takes longer, requires more appointments, and is unquestionably LESS profitable. Another reader said that we recommend removing teeth so that we can charge more. Keep in mind that as specialists, orthodontists do not remove teeth. Instead, we refer patients back to their primary care dentists or oral surgeons for the necessary procedures. In truth, we make more money when teeth are NOT removed. If you honestly believe that your orthodontist's treatment plan was influenced by fees or profit, you really should seek a second opinion.

The number of teeth that will fit in a mouth is determined by the size of lower jaw
A few visitors have inferred that orthodontists who recommend removing teeth are uneducated or old fashioned. The truth is that no matter how young or innovative an orthodontist may be, it is still the size of the lower jaw that determines how many teeth will fit. While there are alternatives to extraction in the upper arch (expanders, interproximal reduction, TADS, headgear, functional appliances, and numerous gizmos that push the top teeth backwards and create space), there are not as many options in the lower. Unlike the upper arch which has a growth plate and extra room behind the molars, the lower arch has more defined limits. Since there is no growth plate in the lower arch, the amount of space available down there is set after the patient has stopped growing.

There are not many options for creating space in the lower arch
All expansion in the lower arch occurs by tipping the teeth outward away from the center of the supporting bone. While abnormally constricted arches benefit by dental expansion, pushing them too far can move teeth right out of the gums and bone. Interproximal enamel reduction can be used in mild to moderately crowded patients, but not enough space can be created for those with severe crowding by merely sanding the sides of individual teeth. The lower teeth cannot be scooted back as far as in the upper arch because of the shape of the lower jaw. Additionally, even when patients choose surgery to move the entire lower jaw forward, this does not produce extra room in the arch for the alignment of crowded teeth. Although there are some heroic procedures like distraction osteogenesis and Wilkodontics, these procedures are invasive, expensive, and rare.

Orthodontist do care about the appearance of their patients!
The most puzzling comments I receive about extractions imply that orthodontists just don’t care how their patients’ faces look at the end of treatment. In another of my blog posts, I outline my three primary objectives in treatment: 1) attractive smiles and faces, 2) healthy teeth, bones, and gums, and 3) post-treatment stability. Sometimes NOT extracting teeth produces smiles that are protrusive and lips that cannot close. Other times NOT extracting teeth pushes teeth out of the gums and bone. Many times NOT extracting teeth produces results which just snap back to their original positions as soon as treatment is complete and retainer wear is relaxed. If removing teeth will give you a smile that is more attractive, healthier, and more stable, that’s the treatment plan that I will recommend.

What's good for the goose...
Like you, I would have loved for my own kids to have kept all of their teeth. This was the most appropriate approach for my two boys. My daughter on the other hand needed teeth removed to give her the best result. I treated her in THREE phases (one of which included an expander) in an attempt to prevent extractions. Ultimately however, her lower jaw was just too small. At the end of the second phase her teeth looked protrusive and she had to strain to close her lips. I discussed all of the options with her and my wife and we all agreed that her front teeth just didn’t look good. I had her four first bicuspids removed, moved her protrusive teeth back into their appropriate positions, and now she looks great! (The picture at the top of this article is actually one of her senior pictures.) The vast majority of orthodontic patients can be treated without removing teeth (over 80% in my practice). For those who just don’t have enough room however, extraction treatment still provides the most attractive, healthiest, and most stable results available.


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.