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

No subject has attracted more attention 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 use this month’s post to address these three concerns.

One visitor 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 commented 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 treatment plan was influenced by fees or profit, you really should seek a second opinion.

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 jaw. 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.

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.

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. 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.

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.

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