Will Bicuspid Extraction Cause TMJ?

After a number of consultations for braces (all recommended Damon), I have been informed by multiple ortho that the extraction of four bicuspid is necessary to adequately address my bite alignment (don't remember if its class I or class II malocclusion), and overbite/deepbite, overjet, crowding and bi-maxillary protrusion. But after doing a little bit of research online, it seems like such an extraction will cause TMJ? Is this true, even if the teeth were to be aligned properly after extraction?

Doctor Answers 7

Extracting bicuspids is RARELY the best treatment option

Extracting teeth would only be recommended if crowding is a major problem.  However, extracting four bicuspids almost always creates excess space that requires upper front teeth to be pushed too far back and arch width to be decreased in order to close the excess space. You must also remember that your face covers the teeth so if you pull your upper front teeth back too far your lower face goes with it. This will often cause your nose to appear large. The doctor who moves your teeth must pay close attention to how it will affect your face.

Tustin Dentist
5.0 out of 5 stars 13 reviews

Bicuspid extractions can cause TMJ

 If orthodontic extractions are recommended, it typically is because of either an overbite or crowding is present.  Both crowding and overbites are the result of the upper jaw being too narrow.  This also sets up the trapping of the lower jaw into a retruded position which is the primary reason for a TMJ Dysfunction to occur. If it is not corrected at the time of orthodontics, then the TMJ problem can surface later, potentially even years after the finishing of orthodontics.  A non-extraction approach is the safest as that approach lets the lower jaw naturally come forward as development occurs allowing healthy TMJ function for the future. .  My advice is to go with an orthodontist who avoids extractions, uses functional orthopedic treatment with a non extraction approach and pays attention to proper TMJ function. 

Kent Lauson, DDS, MS
Denver Orthodontist

Extractions and TMJ

If the orthodontic treatment is well done there is absolutely no scientific proof that extraction of premolars cause TMJ problems.  This does not mean that TMJ problems can not occur after extraction treatment but that this is no morelikely to occur than if the patient was treated without extractions.

Unfortunately, some dentists and orthodontists use the fear of TMJ problems to promote their nonextraction orthodontic philosophy....when in doubt ask for the scientific proof of what they say!

Robert Waxler, DMD, MS
Saint Louis Orthodontist

Extractions do NOT cause TMJ.

There are multiple documented causes of TMJ disorders (TMD).  The most common include a bad bite, stress, tooth grinding, trauma, and oral habits such as constant gum chewing.  Extraction of one or more teeth is not among those causes.  But if the extraction leads to teeth shifting (or being shifted by a doctor) in a way that the bite doesn't fit properly, than you could realistically develop TMJ symptoms.  There are thousands of patients treated every day with extractions who never develop TMJ symptoms.  Likewise there are patients treated without extraction who do develop TMD.  There are even plenty of people with no treatment at all who develop TMD.  Yes, it is a moving target.

With the skill of an experienced doctor and no pre-existing symptoms chances are you will be fine with the approach that they recommend after a careful evaluation. 

Doug Depew, DMD
Atlanta Orthodontist
5.0 out of 5 stars 1 review

DNA Appliance and Expansion Orthodontics is Alternative to Four Bicuspid Extraction

Ideally, expansion is done between ages 3-8 but the DNA Appliance can grow the maxilla in adults.  Recent studies have shown case reports of curing sleep apnea with the DNA Appliance.

Extractions don't cause TMJ but contraction orthodontics can cause TMJ if maxilla causes the lower jaw to be distally displaced,  There is an increased risk of both sleep apnea and TMJ problems after contraction orthodontics.

The DNA Appliance is an excellent tool to finish TMJ cases in phase 2.

Ira L Shapira DDS
Diplomat, American Academy of Pain Management
Diplomate, American Board of Dental Sleep Medicine
Regent & Fellow, International College of CranioMandibular Orthopedics
Chair, American Alliance of TMD Organizations

Ira Shapira, DDS
Chicago Dentist
5.0 out of 5 stars 3 reviews

Extractions for braces is less common today

It used to be standard, pull all 4 first premolars and place braces.  This practice is less common for a variety of reasons, including anecdotal evidence of TMJ issues and sleep apnea complications.  Many orthodontists quote studies stating that teeth have nothing to do with TMJ issues, so it IS debatable.  However, there are strong opinions against those studies, so one must decide for themselves.

If your case is of severe crowding, then pulling teeth may be the only way.  Keep in mind that you may be choosing a 25 mm solution for a 10 mm problem (meaning arch expansion may work as well or better).

In my practice, the EXCEPTION is pulling teeth, not the rule.

Lance Timmerman, DMD, MAGD
Seattle Dentist
4.3 out of 5 stars 6 reviews


It is truly unfortunate when misinformation is disseminated to the unsuspecting and trusting public.  Certainly, matters of professional opinion can differ but are best resolved by professionals and one of those methods is through the use of research and peer-reviewed publication.  Making brash, bold, and unsubstantiated claims and generalizations not based in reality, especially in this type of forum where patients may use the information to make treatment decisions is at best, simply unbecoming of a learned profession.  Statements such as "creates excess," "often cause," "are the result," "primary reason" attended without in fact are a disservice by the uniformed to the layperson.  


The prospective patient is searching for information to make an informed consent and would be best served first suggesting that they personally return to a licensed orthodontic specialist or two to gather this information; not propagating myths. 


First, "Damon" is a name brand of braces and there are hundreds of brands.  It has nothing to do with preventing extractions or reducing TMD.  There is no evidence.  It is marketing. 


In regards to your question, there is a plethora of data on the question at hand.  Doing a simple PubMed search using keywords is a good place to start.  Also contacting the NIH for their position white paper (i.e., paraphrasing "orthodontics is not a cause or cure of TMD (including the extraction of premolars") might be useful.  To give you a start, below is the abstract from a peer-reviewed paper (one of numerous others) that provide with the answer:  Extracting premolars (a procedure that provides substantial improvements for patients that need them) is not a risk factor for TMJ (PERIOD).

Orthodontic risk factors for temporomandibular disorders (TMD). I: Premolar extractions by Kremenak, Kinser, Harman, Menard, Jakobsen, American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 101, Issue 1, Pages 13-20, January 1992.

"Concern about claims that premolar extractions may put patients at risk for temporomandibular disorders (TMD) led to this study. We report first findings from a longitudinal study of orthodontic patients begun in 1983. By using the methods of Helkimo, we collected TMD data before initiation of orthodontic treatment, between 0 and 12 months after debanding, and 12 to 24 months after debanding. Analyses related Helkimo scores with premolar extractions in 65 patients for whom orthodontic treatment had been completed. Twenty-six patients were treated without premolar extractions, 25 had four premolars extracted, and 14 had two upper premolars extracted. Tests for significance of differences between mean Helkimo scores were conducted for the nonextraction group compared with the extraction groups, and between pretreatment and posttreatment Helkimo scores for each group. Results included: (1) no significant intergroup differences between mean pretreatment or posttreatment scores, and (2) small but statistically significant (P < 0.05) differences (in the direction of improvement) between mean pretreatment and posttreatment scores for both the nonextraction group and for the four premolar extraction group."



Steven Jay Bowman, DMD, MSD
Portage Orthodontist
4.0 out of 5 stars 1 review

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.