Whether or not to extract any teeth and, if so, which ones should be discussed by the clinician and the patient on an individual basis. The current trend is towards nonextraction of permanent teeth whenever possible. Minor crowding can usually be relieved without any dental extractions by using fixed or removable appliances to expand the jaws.

Most patients seek orthodontic evaluations because they notice dental crowding in their mouths. Moderate to severe crowding can require extraction of teeth to relieve crowding. Which teeth to extract is controversial. Traditionally, the four first bicuspids (two from the upper arch and two from the lower arch) are extracted. Removal of the first bicuspids is easy to perform and is especially beneficial for those patients with protrusive looking faces. However, some dentists are now recommending removal of the second molars instead of the bicuspids to relieve crowding.

The option to extract second molars is favored in some cases because it allows for a fuller smile with ten incisors and bicuspids in each arch as opposed to eight incisors and bicuspids. It also makes room for the wisdom teeth (third molars) to develop properly. In the absence of second molars, wisdom teeth generally erupt into the position of the second molars.

Thus, the often difficult surgical extractions of wisdom teeth are avoided by allowing them to grow and erupt into the space of the extracted second molars. In the few cases where the wisdom teeth do not erupt into the vacated second molar positions properly, minor orthopedic appliances can be used at the time of their eruption to guide them into desired alignment.