Premolar Extraction Patterns- upper bi’s vs 4bi’s

First of all, I want to preface this blog that I’ve avoided writing this blog because I am emphatically against premolar extractions for a zillion reasons. Most of the time it’s overkill and not necessary, especially with early intervention. That being said, I want to give my “rules” for extractions:

1. Always, always get a ceph and ceph numbers before even considering any extractions. Watch our content on cephs to learn why and how to interpret or schedule a session with us at for hands-on help with a case.

2. Consider alternatives like IPR, expansion, proclination and distalization (which is SO easy with invisalign and elastics for anchorage as long as the 8’s are extracted!)

3. Always, always screen for OSA and never initiate extractions on any patient who might be at risk for OSA. That means, asking questions, doing an exam and referring as needed if you don’t know. Document, too! If you don’t do OSA and refer and collaborate with a sleep MD in your practice, you aren’t qualified to make this decision. This is a liability. Don’t skip this step!

4. There is ABSOLUTELY NO reason to extract on a growing kid. This isn’t standard of care IMPO. That’s my opinion and the opinion of many orthodontists and likely also a dental board, if questioned. Why risk your license because a parent is pushing you? Extractions are always last resort and growing kids shouldn’t be guinea pigs for sloppy ortho. Refer to someone who can treat properly.

If you’ve done all of the above and you still think the patient is a candidate for extractions, here’s my cookie-cutter approach:

1. You only take out upper bi’s when you are full step class II and only if and only if you’ve exhausted other options above. Use a TPA or nance for anchorage.

2. You only take out 4 bicuspids when the patient is class 1 with severe crowding. If you are worried about profiles, do 5’s but to me those are bigger teeth so extract closer to the crowding.

3. If the patient is slight class 2 with severe crowding, do upper 4’s, lower 5’s but consider a TPA or nance or anchorage.

4. If the patient is slight class 3 (less than 2mm) with severe crowding do upper 5’s, lower 4’s but consider additional, lower anchorage like a LLHA.

5. If there’ is asymmetry, you’ll need to get creative and/or if one premolar is has a less favorable prognosis (eg- perio/endo/caries..etc). It makes the mechanics a bit tricky but it’s doable and the patient will appreciate it.