Four Healthy Teeth Out to Straighten the Rest

Quick answer: Removing healthy premolars for orthodontics feels wrong to most parents, and it is a legitimate thing to question. In genuinely crowded mouths it creates the space needed for a stable result, and the alternative — pushing teeth outwards to make room — has its own significant costs.

The call

A father in Beit Shemesh brought his 14-year-old, Yonatan, with an orthodontic treatment plan in his hand and one question: is it really necessary to take out four perfectly good teeth?

That is exactly the right question, and it deserves a proper answer rather than a shrug towards the orthodontist.

What we found

Severe crowding. About 9mm of space deficiency in the upper arch and 7mm in the lower — meaning that if you lined the teeth up properly, there was that much more tooth than there was jaw to hold it. Two upper canines were completely blocked out and erupting high in the gum. The lower incisors were overlapped and rotated.

The orthodontist had proposed removing all four first premolars, the teeth just behind the canines.

The reasoning is a matter of arithmetic, not preference. Crowding is a mismatch between tooth width and arch length, and there are only three ways to resolve it:

Create space by expanding the arch. Effective in growing children with a narrow upper jaw. Limited in the lower jaw, where pushing teeth outwards moves them out of the bone. Overexpansion risks gum recession and relapse.

Create space by slimming the teeth, removing a fraction of a millimetre of enamel between each. Useful for mild crowding, up to about 3 to 4mm across an arch. Nowhere near enough here.

Create space by removing teeth. The reliable option for severe crowding. A premolar is about 7mm wide, so two per arch resolves substantial deficiency.

Why premolars specifically? They are near the middle of the arch, so the space can be used at the front or the back. They are the least visible teeth to lose. And the arch functions perfectly well without them — the canine ends up sitting next to the second premolar, and nobody can tell.

There is a real debate in orthodontics about extraction versus non-extraction, and legitimate criticism of eras when extractions were overused, sometimes flattening facial profiles. That debate applies to borderline cases. At 9mm of crowding with blocked-out canines, it does not.

What we did

We spoke to the orthodontist directly before doing anything, confirming which teeth and the intended timing — extractions too far ahead of the appliance being fitted allow the spaces to close in the wrong direction.

All four premolars removed in one appointment, under local anaesthetic, about forty minutes. Straightforward single-rooted teeth in a healthy 14-year-old. Braces were fitted three weeks later.

Yonatan was given the standard aftercare, and both painkillers before the numbness wore off.

The outcome

Two years of orthodontic treatment. The canines were brought down into the arch, the crowding fully resolved, and the spaces closed completely. His profile was unchanged — we compared the before and after photographs, which is worth doing.

He now wears retainers, which, as another of our stories makes clear, is the part that determines whether any of it lasts.

What to do if this happens to you

1. Ask how much crowding there is, in millimetres. A specific number tells you whether extraction is genuinely needed.
2. Ask what the non-extraction alternative would involve and what its risks are.
3. Ask about the effect on the profile. A good orthodontist will have considered it and can show you.
4. Get a second opinion for borderline cases. Under 4 or 5mm of crowding, alternatives may exist.
5. Confirm the timing with the orthodontist before booking the extractions.
6. Do not delay once the plan is agreed. Adolescent growth is a resource with an expiry date.

Orthodontic extractions recommended? Ramat Beit Shemesh Urgent Dental Care coordinates with your orthodontist. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh.

Based on real cases treated at the clinic. Names have been changed.