Removing Teeth for Orthodontic Treatment

Why tooth extractions might be necessary to straighten a smile

Orthodontics, the art and science of moving teeth into better positions, allows us to transform a crooked smile into one that is beautifully aligned. Exactly how this is done depends on several factors, including the desires of the patient, the training and experience of the orthodontist, and the age at which treatment begins. But by far the most important consideration for successful orthodontic treatment is the condition of an individual’s mouth: What type of malocclusion (“mal” – bad; “occlusion” – bite) needs to be corrected? How far will the teeth have to move to end up in the right place? What is the size of the jaw relative to the size and number of teeth? The answers to questions like these will determine how best to proceed. And sometimes these answers will point to the extraction of a tooth or multiple teeth.

It may seem obvious to say that each person is unique, yet I find myself having to do this a lot in the age of the internet. Patients are more informed than they ever have been, with most people reading up on various methods of orthodontic treatment before the first consultation. This is especially true of parents, who often express a desire for their children to avoid tooth extractions; they would prefer interceptive techniques they have read about, such as palatal expansion. This is often possible—but it won’t always allow us to avoid tooth removal, and it may even lengthen treatment time without benefitting the child. It all depends on the anatomy of that one unique person sitting in the orthodontist’s office.

Orthodontists can get a very accurate picture of what needs to be done using x-ray images, photographs and models of the mouth. These, along with precise measurements and clinical experience, point to the best treatment options. Sometimes they point to the removal of teeth as the best choice. Let’s take a look at some orthodontic problems where this might be the case.

Severe Crowding

Severe crowding of teeth occurs when the upper and/or lower jaw is not large enough to accommodate all of the teeth that are present (or growing in). This causes some teeth to be pushed out of alignment. In an adult, tooth removal will almost always be recommended because the patient does not have any growth potential that could create more room for the teeth. In a child who has not yet reached puberty or lost all their baby teeth, we may have some other options.

In the lower jaw, for example, there are two baby teeth that are actually one to two millimeters larger than the adult teeth that will eventually replace them. These are the second primary molars (the lower teeth that are the farthest back on either side). If orthodontic treatment starts early enough, we can carefully monitor these two teeth. Before they are lost, we can fit the child with a very simple device called a space maintainer that holds this space open at the original size. This may give us enough room to straighten the teeth without having to remove any—but not always.

In the upper jaw, the size discrepancy between the primary and permanent molars is not as great, and this same technique isn’t always useful. In many patients, orthodontists will recommend a palate expander—a device that can be used in growing children to gradually make the upper jaw bigger by widening the developing bones of the palate. This treatment creates more space in that jaw, and also has the benefit of widening the child’s airway. If the child has sleep-related breathing issues (snoring, sleep apnea, etc.), a palate expander should be considered. But just because we use a palate expander, there still might not be enough room to accommodate all the teeth. In that situation, the orthodontist will recommend tooth removal.

Impacted Teeth

When a tooth is blocked from growing in and remains at least partially submerged beneath the gum and/or bone, it is said to be impacted. It is often possible to attach special orthodontic hardware to these teeth and pull them into correct alignment. But in some situations, they are too far out of alignment to make this a good option. In that case, the impacted tooth might need to be removed, possibly along with the matching tooth on the other side to keep the smile in balance.

Protrusion of Front Teeth

Teeth that stick out horizontally are referred to as protrusive. In severe cases, protruding front teeth can prevent a person from being able to close their lips. Braces and other orthodontic appliances can be used to bring the teeth into better alignment, but teeth will often need to be removed in order to create the space that’s needed to do this.

Congenitally Missing Teeth

Sometimes one or more permanent teeth never grow in, leaving the smile with gaps or an asymmetrical appearance. A person in this situation may opt to replace the missing tooth (or teeth) with bridgework or a dental implant. However, if it is just one tooth that didn’t grow in, another good option might be to remove the same tooth on the other side for symmetry and then close the gaps with braces. This kind of treatment can provide an aesthetically pleasing result, and may be simpler and less costly to accomplish than tooth replacement.

Severe Skeletal Issues

Sometimes when teeth don’t fit together properly, it’s actually a problem with the way the jaws are aligned. For example, a severe overbite could result from a lower jaw that is too far back. Generally, the best way to correct this in an adult is to surgically reposition the jaws so that the lower jaw is brought farther forward. But some people would prefer not to have jaw surgery. In that case, it may be possible to remove two upper teeth and then use braces to move the rest of the teeth back. This makes the overbite less noticeable—but it can also narrow the airway, and therefore must be approached with caution.

In all of these situations, the size and position of the teeth and jaws will determine which treatment options are possible. It’s essential for the orthodontist and patient (or parent) to have a detailed conversation about the treatment plan before orthodontic treatment is started. That way, options can be explored, questions answered and expectations kept realistic. Anyone who undergoes orthodontic treatment deserves a treatment plan as unique as they are—along with an understanding of why it might make the most sense to remove teeth after all. Still, dentistry is a profession focused on saving teeth and no one wants to remove a tooth unless it is in the patient’s best interest.