2 opinions, different orthos, I have to guess who is right

Message

#1 Post by **Joual** » Mon Oct 30, 2006 6:32 pm

Okay, I've had consults with 7 (yes, 7) orthos.

5 orthos told me that I need 4 bicuspids/premolars extracted. 2 orthos highly disagree with that.

2 orthos told me that you absolutely cannot extract lower bicuspids in my mouth because my bite would be all wrong if that happened. Those 2 orthos said that 2 upper bicuspids have to be extracted, and they would file the sides of some lower teeth to make them smaller. I have an overbite and mild crowding on top, severe crowding on the bottom.

They said that my top teeth would be too far ahead of my bottom teeth if I had lower premolars extracted because my lower jaw is a little further back than my upper jaw.

They've been doing ortho since the 1970s, so they know their stuff....or maybe their opinion is outdated. When I told them that what they said was different from other opinions, they were appalled that anyone would tell me that I need bottom bicuspids extracted.

One ortho who said I need 4 extractions was adamant that what you remove from the top you have to remove from the bottom. He also told me that my lower jaw is a little further back than my upper jaw.

He's been doing ortho for less than 5 years, so maybe he needs more full-time real-world experience. Or maybe his info. is more current since he's a fairly recent graduate.

The other orthos I've seen have been practicing anywhere from 12 - 25 years.

All of these people have a certificate in orthodontics and some of them have an MS degree in oral sciences. Some of them are professors in the ortho dept. at the dental school at the university here.

One opinion is wrong. Or maybe both opinions are right.

If any of you have heard conflicting opinions on your teeth I would appreciate hearing about how you dealt with it and if you feel you made the right decision.

#2 Post by **Delag** » Mon Oct 30, 2006 6:48 pm

Hi Joual and welcome to the best board on the Web. First off - kudos to you for doing your homework and getting lots of opinions. I saw several orthos as well and was glad I did. It is hard to say what the *best* decision is, but my gut feeling would be the fewer extractions the better. If it doesn't work and you need them in the future, it will still be an option - if you get them done now there is no turning back. I would hate to see you need an avoidable jaw surgery to even things up if the two orthos are correct.

#3 Post by **Joual** » Mon Oct 30, 2006 7:41 pm

Delag - I saw your thread about IPR, which is what the 2 orthos want to do with my bottom teeth. My hairdresser told me she would rather get 4 extractions than get top extractions and bottom teeth slenderized. She's had consults with orthos who told her she needs 4 bicuspids out. No one told her that they would slenderize any of her teeth. She thought it was so odd that orthos told me that.

Meryaten - Thanks so much for that info. I'm going to e-mail that to my mom. She thinks it's really weird to get 2 out on the top and none out on the bottom. She had 4 biscuspids extracted when she had braces.

KK - You're right, my main issue is whether to have 2 or 4 extracted for a correct bite. I'm ok with removing 2 bicuspids from my upper jaw only because that is the one thing that is unanimous among all the orthos I've seen.

#4 Post by **ohmyjaw** » Tue Oct 31, 2006 12:43 pm

Hi Joual,

This is a tough one! Personally, I would go with an ortho with a more conservative approach. I had 2 perfectly healthy teeth extracted as a kid, which was a big mistake. Now, as an adult I need to get an artificial tooth/implant.

I had one tooth removed from the upper jaw and one from the lower. I am glad we stopped going to that orthodontist when we did, because he wanted to extract more teeth and that would have left me even worse off.

The orthodontist I have now said he can probably work around the fact that the bottom tooth is missing, but not the top one. That is where I need the implant. So, I guess a person can have unequal numbers of teeth between top and bottom, and in my case even between left and right sides of my mouth.

Like others said, I would go with the ortho you feel most comfortable with, and be conservative because you can always take out the teeth later if necessary, but once they are gone, they are gone.

#5 Post by **Regina Rose** » Tue Oct 31, 2006 3:44 pm

Joual, it is absolutely not the case that you always need to remove bottom teeth if you remove upper ones. I'm also being treated for an overbite. My orthodontist initially was thinking I would need two bicuspids removed from each arch but has since changed his mind. He is now hoping to avoid lower extractions with some selective interproximal reduction (also called shaving or slenderizing the teeth). If I'm understanding him correctly, more teeth in the lower arch is preferable in my case because it will stabilize my corrected overbite better (he told me about this just before I had my upper bicuspids pulled and I was a bit distracted at the time).

It is almost always better to avoid extractions (except for wisdom teeth) if at all possible. If you have two orthos in agreement that lower extractions are not necessary, I would follow up with one of those docs.

#6 Post by **Joual** » Tue Oct 31, 2006 7:48 pm

Needing implants in the future is a fear that I have, so I'm leaning towards the 2 who said they would do interproximal reduction/shaving on the bottom. I guess the worst case scenario would be that I would need veneers if that went wrong.

#7 Post by **ohmyjaw** » Thu Nov 02, 2006 1:45 pm

Hi Joual,

I hope I didn't scare you with my ortho story. Lots of people get teeth extracted as part of their ortho treatment, and it's quite normal. Someone like me, who had teeth removed and now needs an implant, is a rarity. The guy I had was really quite incompetent.

I don't think you need to start your treatment thinking about "the worst case scenario" before anything has even happened.

I would only suggest, because you have two different opinions, to go with the one that is more consevative. That way, if it turns out they are right, and you are better off with just 2 teeth removed, you made the right choice.

If it turns out they are wrong, and you really do need 4 teeth removed, that can always be done later.

The "slenderizing" of teeth is also quite normal, I believe. I know it is something that my ortho does with some of his patients, and I again I wouldn't be overly nervous about it going wrong. Make sure you tell your ortho about your concerns- how they respond might give you an indication if you are going to comfortable working with them.

Best of luck with whichever you decide to do!

#8 Post by **Lisa65** » Thu Nov 02, 2006 2:11 pm

Having extractions and unsuccessful orthodontic treatment in my teens actually made my situation worse. I had all 4 1st bicuspids extracted and a removable device similar to a Hawley retainer which dragged my canines back into those gaps but didn't address my overjet or overlapping front incisors. I also had my wisdom teeth out at the age of 21. At the bottom the gaps never closed properly, and over time my back teeth moved forwards into the gaps, which means a huge amount of work for my ortho now, there are no more teeth he can extract as I then wouldn't have enough left. I have all kinds of hardware in my mouth to drag those molars back to somewhere near where they should be, and I will need IPR as well.

I guess it's all different now almost 30 years on, and things would have been done differently. But I'd also suggest that you went with just the 2 extractions and the IPR, because if later on it turned out that those teeth did need to come out, it could be done later. But there's no way of putting them back once they're out.

#9 Post by **Rickysa** » Thu Nov 02, 2006 2:31 pm

Hi Joual,

Removing teeth (2 or 4) is dependent on how your first (6-year) molars fit together.

Here are the terms:

Class I means the molars fit correctly
Class II means the upper molars are ahead of the lowers
Class III means the upper molars are behind the lowers

Teeth in the mouth fit together like teeth on gear...you have to have the right size and the right number of them for things to mesh.

If you take two upper teeth out when the molars fit correctly, you will have to few upper teeth to mesh with the lower and have an underbite

If you take out two teeth on the lower when the molars fit correctly, you will have to few lower teeth to mesh with the upper and have an overbite

If your molars fit correctly, you need either 4 bicuspids out or none.

I've been practicing for 14 years and would be happy to answer any PMs!

Dr. Rick

#10 Post by **Rickysa** » Fri Nov 03, 2006 5:13 am

KK wrote:So wonderful to have a post from you on the board Dr Rick!

You have been very missed!

OOPS!

I'm a different Dr. Rick!!! So sorry for the confusion, but I hope I can help answer any questions folks might have

Dr. S

#11 Post by **Joual** » Fri Nov 03, 2006 6:56 pm

ohmyjaw - You didn't scare me! When I started getting consults I was not expecting to hear that I needed extractions. I thought that the first ortho I saw was absolutely crazy! I guess I'm still not over the shock even though I've had so many orthos tell me I need extractions.

Lisa65 - Thanks for sharing that. I hope that your treatment goes well.

Dr. Rick - Thanks so much for your input. I didn't know what the different classes meant or how they related to extractions.

#12 Post by **DrBill** » Sun Nov 05, 2006 10:42 am

Hi Joual,

Unfortunately a situation like yours is often challenging in adults due to the lack of growth. I'll try to put the two differing opinions into perspective for you (I've been practicing 9 years).

It sounds like you have a Class II malocclusion and, as you mentioned, significant lower crowding. While Rick explained the bite classifications from a molar perspective, we can also classify the canines. One of our goals as orthodontists is to establish a Class I canine, which means the upper rests behind the lower in a front to back direction. The orthodontists who suggested extracting two upper premolars did this because it allows retraction of the upper canines while the lower canines stay put. If you extract lower premolars as well, the lower canines move backwards (they're already back too far in a Class II malocclusion) and it can be difficult - sometimes impossible - to establish a Class I canine.

However, the orthodontists who suggested extracting 4 bicuspids did so because of the lower crowding. If a patient is too crowded and you don't extract in the lower, the incisors dump forward and can become excessively protrusive. This can be unesthetic and negatively affect your profile.

Hence your dilemma. In a growing patient, it's much easier to extract 4 premolars in a Class II patient because even though the lower canines move back in the jaw, the jaw itself is moving forward and we can still get a Class I canine with headgears and other appliances. Not so in an adult.

So which option is best? There may be no perfect answer, but here are some things to think about.

1) Ask your orthodontists how Class II you are. A "full step" would lean me away from extracting in the lower, a "half step" may make lower extraction more viable.

2) When in doubt, you can always align the lower teeth and then decide about extraction. It roundtrips a little bit but also may give you peace of mind. If the teeth look ok to you and you're committed to lifetime retention you should be ok non-extraction.

3) Sometimes in adult treatment we have to compromise due to the lack of growth. Is it more important to you to reduce the jetting out of your top teeth or avoid protrusive lower teeth even though some overjet may remain? Occasionally, to get a more ideal result, we compensate for the lack of growth with jaw surgery.

4) A third option not mentioned that can occasionally be used in a situation like yours is extracting the upper premolars and one lower incisor. This way the lower canines are not retracted. However, the viability of this option depends on the size of your front teeth. I assume your doctors would have mentioned it if it looked like a good alternative, but it wouldn't hurt to mention it.

While I got a bit technical, hopefully this made some sense and good luck!

#13 Post by **Joual** » Sun Nov 05, 2006 2:56 pm

Thanks so much DrBill. One ortho mentioned extracting the upper premolars and one lower incisor. I knew immediately that I didn't want to do that though, because I want a midline on the bottom. He's one of the orthos that said he would minimize the bottom teeth and I'd keep my bottom premolars.

#14 Post by **AngelaMiller** » Wed Jan 21, 2009 4:58 pm

I am not a dentist; however, I was a victim of unsuccessful orthodontic treatment.

I think the biggest guide for whether or not you let them extract teeth should be your face. Understand that after your teeth are extracted, they will close the gaps making your arch often times smaller.

When your arch gets smaller, your lips do not have as much support.

You should ask yourself, can I afford to have my less lips? How big is my arch to start with? If you are someone with that doesn't have much lips to begin with, extractions may be undesirable.

If you are someone with overcrowding that has a big arch anyway it may not be too bad.

#15 Post by **Jewles** » Wed Jan 21, 2009 7:31 pm

she posted it over two years ago

im hoping shes made a decision by now hehe