Extractions: Understanding Tooth Removal in Orthodontics

When it comes to orthodontic treatment, there are a number of different ways to correct misalignments of the teeth and jaws. One treatment option that can sometimes raise questions and concerns among patients is tooth extractions. While removing teeth may sound concerning in the context of orthodontics, there are situations where extractions are necessary to achieve the best long-term results. In this post, we’ll take a closer look at why extractions are sometimes required in orthodontic treatment and how the space left behind is typically closed.

We Always Try to Avoid Extractions, But Sometimes They’re Necessary

As orthodontists, our first priority is always to preserve the natural teeth whenever possible. We understand the emotional and aesthetic concerns that patients have about extractions, and we strive to avoid them if we can achieve the good results through other means. That's why non-extraction treatment plans are often the preferred choice.

However, there are situations where extractions are not just beneficial but necessary.

Why Are Extractions Done in Orthodontics?

To understand when and why extractions might be necessary, it's important to know that orthodontics aims to create a healthy, functional, and aesthetically pleasing bite. In many cases, achieving that goal involves aligning the teeth, improving bite relationships, and ensuring there’s enough space for the teeth to fit comfortably in the mouth.

Tooth extractions are often considered when there’s severe crowding in the mouth or when there are bite issues that would be difficult to correct without creating more space. The reasons for extractions can vary, but here are the most common situations:

1. Severe Crowding

In cases of significant crowding, there is a big difference between the size of the jaw and the total size of the teeth that must fit in that space. If there’s insufficient space in the mouth for all of the teeth to align properly, orthodontists may recommend extracting one or more teeth to create the space needed for proper final tooth position.

2. Bite Problems (Malocclusions)

Certain bite issues may require extractions to create the necessary space for proper alignment. For example:

• Overbite or overjet (when the upper teeth protrude too far over the lower teeth) may require extractions to create room for the upper teeth to move back into alignment.

• Open bite (when the upper front teeth do not overlap the lower teeth) may also require extractions to create space to close up the bite and allow proper alignment.

• Underbites (where the upper teeth bite behind the lower teeth) may be addressed with extractions to help realign the teeth.

  
  

3. Protrusion of Teeth

In some cases, the upper or lower front teeth may be overly protruded or flared out due to lack of space. Removing teeth can help bring these teeth back into alignment, creating a more balanced and aesthetic smile.

4. Orthodontic Preparation for Jaw Surgery

In certain cases, orthodontists will extract teeth to prepare for jaw surgery (orthognathic surgery). For example, in cases of severe skeletal discrepancies, extractions may be necessary to create space before surgery can be performed to realign the jaws.

What Happens If We Don’t Extract and Rely Too Much on Other Space Creation Methods?

In some cases, orthodontists may attempt to avoid extractions by relying heavily on interproximal reduction (filing between the teeth), expansion or proclining (forward movement) of the teeth to create space. This approach can be successful in some situations, but there are limitations, and overusing these methods can have consequences.

Here’s what may happen if we try to avoid extractions and rely too much on these other methods:

1. Facial Aesthetics May Be Affected

Proclining (pushing teeth forward) is often used to alleviate crowding, but it can lead to an overly prominent smile, with the upper front teeth sticking out more than is aesthetically pleasing. This can result in a less harmonious facial appearance, with the front teeth appearing slanted forward.

2. IPR May Not Be Sufficient for Severe Cases

IPR, or slightly filing down the sides of teeth, is a technique used to create small amounts of space between teeth. While this can be helpful for minor crowding, it often isn't enough to address significant misalignments. Using too much IPR in an attempt to avoid extractions could lead to too much enamel removal, compromising the health and integrity of the teeth.

3. Increased Risk of Relapse

Over-expanding or excessive proclining without extractions can lead to crowding returning after treatment. This is because the space created might not be properly maintained over time, and the teeth may shift back into their previous positions as they are not being anchored into their new positions. Retainers and long-term maintenance are crucial in these cases, but even with retention, there's always a risk of the teeth gradually wanting to move to more stable positions.

4. Risk of Bone and Gum Tissue Loss

Moving teeth too far without extractions can lead to bone and gum tissue loss around the teeth. When teeth are proclined or expanded too much, the supporting bone may not be able to keep up with the rapid movement, resulting in bone resorption (loss of bone tissue). This can lead to gum recession, tooth mobility, and potential long-term periodontal issues.

4. Difficulty in Correcting Bite Problems

Some bite problems, like open bites or severe overbites, may not be fully corrected by expansion or IPR alone. In these cases, extractions are often the most predictable solution to create enough space to achieve the ideal bite. Trying to avoid extractions might leave the bite misaligned, potentially requiring further intervention later on.

5. Possible Impact on Jaw Growth (in Children)

In growing children with narrow upper jaws, expansion can help to widen the jaw and create space for the teeth. However, expanding too much (or expanding when there is no narrow upper jaw) can cause jaw discrepancies. For example, excessive maxillary expansion (upper jaw widening) can lead to unstable bite patterns and negatively affect how the upper and lower jaws come together. In such cases, it's often better to consider extractions to balance the teeth and jaw alignment more effectively.

How Is Space Closed After Extractions?

Once extractions are made, the space left behind is typically closed using braces or clear aligners. The adjacent teeth (the teeth next to the extraction sites) are gradually moved into the empty space. This movement is controlled by anchorage, which is a method of applying forces to prevent some teeth from moving too much while others move into the space. Techniques like elastic bands or coil springs may be used to help close the gaps efficiently.

The time it takes to close the space after extractions varies depending on factors like the amount of space, the patient’s age, and the complexity of the case. On average, closing space can take anywhere from 6 months to 2 years, with most cases falling somewhere in the middle. The orthodontist will regularly monitor progress and adjust the treatment plan as necessary.

So, what does this all mean?

Tooth extractions in orthodontics are sometimes necessary to create enough space for proper alignment, address bite issues, and improve facial aesthetics. While the decision to extract teeth can seem daunting, it’s often a carefully considered step in achieving the best possible long-term outcome.

The process of closing the space after extractions is typically accomplished through braces or clear aligners, and the treatment plan is tailored to each patient’s specific needs. If you’re considering orthodontic treatment and have concerns about extractions, it’s important to have an open discussion with your orthodontist to weigh the benefits and potential risks.

Orthodontic treatment is an investment in your oral health and overall appearance, and with the right plan, you can achieve the smile you’ve always wanted!