Extractions in conjugation with the braces treatment are not new. To establish straight teeth in functional occlusion, extraction of teeth is required. The crookedness of the teeth and the age of the patient may be the important factors in deciding whether extraction is required or not. Extractions in orthodontics include serial extraction carried out when both milk teeth and baby teeth are present and therapeutic extractions which are carried out as a treatment procedure for gaining the space.
To extract or not to extract has always been a controversy in orthodontics. Some orthodontics advocates non-extraction while some recommend extractions.
Need for pulling out teeth for braces treatment
A number of circumstances necessitate extraction of teeth as a part of braces treatment. These are:
1. Arch length-tooth material discrepancy
The arch length and tooth material should be in harmony with each other. The presence of tooth material in excess of the arch length can result in crowding of the teeth or proclination of the front teeth. In many cases, it can’t be treated by increasing the arch length so tooth material is reduced in such cases. Extraction of one or more teeth is done in case of severe tooth material-arch length discrepancy. Usually an orthodontist will first pull out the wisdom teeth. If there is still not enough space, then bicuspids are pulled out.
Crowding and Proclination of teeth due to Arch length-Tooth material discrepancy
2. Correction of inter-arch relationship:
Abnormal malrelationships may require extraction of the teeth to achieve normal inter-arch relation. Pulling out teeth in such cases establish normal incisor and molar relationship
3. Abnormal size and form of teeth:
If the teeth are abnormal in size or form, then extraction is required to achieve satisfactory occlusion. Abnormal teeth can be quite larger in size than the normal teeth, hypoplastic, teeth with curved roots or crown or teeth with abnormal appearance.
4. Skeletal jaw malrelations:
Severe skeletal malrelationship of the jaws may not be treated with orthodontic appliances only. Surgical respective procedures along with extractions are required in these cases.
Severe crowding and malalignment before the Braces Treatment
Teeth after 2 years following Braces Treatment with 4 Teeth Extraction
Choice of teeth for extraction
The choice of teeth for extraction is based on no of factors. These are:
Arch length tooth material discrepancy
Direction and amount of jaw growth
State and position of teeth
Age of the patient
Bicuspids are most commonly extracted teeth as a part of braces treatment.
To relieve moderate to severe crowding and proclination, first bicuspids are removed and to relieve mild crowding and proclination, second bicuspids are removed. In case of open bite, extraction of second bicuspid is preferred over the first bicuspid as deepening of bite is encouraged.
When the space required is less than 5mms but more than 2.5mm, then second bicuspids are removed and when the space required is more than 5mms, then first bicuspids are removed.
Extraction of second bicuspids for Braces Treatment
The teeth must be symmetrical. Same teeth are usually removed from top and the bottom. If two teeth are removed from the same side, then midline shift can occur. So the teeth are usually removed in either 2’s or 4’s. More commonly 4 teeth are to be extracted.
Extractions in Children
Extraction in children is not advocated. Extraction for braces treatment is usually done in adults. Growth in children is still taking place and additional options can be looked for in them apart from pulling out the tooth. The space can be gained in children by use of headgears, palate expansion or by guided growth method. In case of class III malocclusion, in the lower jaw is in the front of upper jaw, extraction may be required.
Who pulls out the tooth?
The tooth is pulled by an oral surgeon mostly. A simple dentist with tooth extraction training can also do the extraction.
How painful is the extraction?
In case of wisdom teeth extraction, sedation is mostly given. There may be pain and discomfort few days after extraction depending on the procedure used to pull out the tooth. Sutures may also be given after the tooth is pulled out.
In case of extraction of bicuspids, usually there is no pain or discomfort afterwards. The extraction is done under local anesthesia. It takes around few minutes to pull out the four bicuspids. Before the extractions, it is advised not to take any pain meds or anti-inflammatory tablets as they prevent clot formation so more of bleeding occurs.
After the teeth are pulled out, analgesics that are the pain pills are given by the dentist. It is advised to take soft and liquid diet and not to smoke minimum for 48hrs and to avoid sucking, spitting for a minimum of 24hrs. It is also advised to do warm saline rinses 24hrs after the tooth removal for proper healing to take place.
A dry socket can occur as a complication after the extraction if the clot gets dislodged or dissolves exposing the bone. The chances of dry socket increases in case if a person smokes within first 48hrs after the tooth removal or if the patient sucks or spits, quite a lot after extraction or if the patient doesn’t follow the postoperative instructions. In such cases, the socket area is first cleaned and then the dressing is given.
When Are the Braces given after extraction?
The orthodontist can give braces almost immediately after the tooth is pulled out. He may put on the braces a day after extraction only.
Gaps in mouth after teeth are pulled out
The patient may find gaps in the mouth very awkward. While eating, the patient has to change the way of chewing. He has to chew slowly and has to take small bites. There should be no food accumulation in the gaps. The chewing habits have to be changed until the gap closes.
With the lapse of time, the gap will start decreasing. As the gap decreases, the way the person bites and the way the teeth meet also changes.
In some rare cases, front teeth may also require to be pulled out for braces treatment. Missing front teeth is quite noticeable. So a person might be quite embarrassed because of it. But this is for a short span only. The gap will close within some time and the teeth will become straightened.
After how long does the gap closes?
The time taken for the gap to close varies from person to person and case to case. On an average it takes 4months to 1year for gap to close. The gaps which are present on the upper teeth closes faster than the gap present in the lower teeth. The movement of the teeth per month is about 1millimeter.
To close the gaps, power chains or some other methods can also be used. On some of the brackets, hooks are present to which power chains are attached. The power chains can also be put in place of ligatures directly on brackets. Lighter shades power chains get stained easily so it’s very to go for colors which don’t stain as grey color. Loops in the arch wire can also be made to close the gaps. It is usually done near the completion of the treatment and is so called as closing or finishing loops at times.
Tooth with the chain around it, which is covering up the wire that's on it as well
The orthodontist can check that whether the gap between the teeth is reducing or not by a special ruler. Initially a person might feel that the teeth are not at all moving but in actual they are.
An extra wire may poke at the soft tissue when the gaps are closing. This occurs quite often. In such cases, an orthodontist needs to be consulted asap. The extra wire is trimmed by orthodontist. To prevent poking for a time being, wax can be used.