Extractions in orthodontics are sometimes necessary, as cruel and unfortunate as this may sound to patients. Pulling teeth is often the only way to make room for the other teeth to align and the jaws to fit better together. But you may be wondering about the perfect timing of these extractions – should they be done before or after getting braces?
It’s perfectly normal to get braces and then have extractions done. While pulling wisdom teeth is better done before getting braces, removing premolars can be done whenever the orthodontist decides it’s the best time.
Sure, extracting teeth with the braces on does come with some risks, but they’re minimal, and your surgeon knows what they’re doing. In this article, I’ll explain why teeth don’t always get extracted at the beginning of orthodontic treatment.
The extraction decision – should you give up healthy teeth for a straight smile?
Extracting healthy teeth in orthodontics has sparked a passionate debate among professionals over the years. Common sense says we shouldn’t do it, yet, when our patients have small jaws and large teeth, there’s really no way around it.
My cases are split 50-50 between extraction and non-extraction, and it’s really the moderate crowding cases where it’s toughest to decide – because the best thing for the patient is not always obvious.
This article is not meant to convince you that pulling teeth in orthodontics is good or bad, but rather to show you the most common situations where you might need to go the extraction route:
- Crowding over 10mm typically requires extractions.
- Dental protrusion (teeth sticking out, the patient has trouble bringing lips together) requires extraction and/or surgery.
- Various severe malocclusions (severe protrusion, underbite, asymmetries, open bites) may require surgery and/or extraction
- When patients refuse maxillo-facial surgery, they often accept extractions as a means of ‘orthodontic camouflage’.
The teeth that get pulled most often are, you guessed it, wisdom teeth. But they’re not the only ones getting sacrificed in the name of braces. Here’s a complete list of all the teeth that may get extracted to make more room:
- impacted or non-impacted 3rd molars (wisdom teeth)
- 1st or 2nd premolars
- one lower incisor
- molars (in extreme open bite cases, or when they’re decayed)
- supernumerary teeth (they’re not supposed to be there in the first place)
- misshapen teeth (often, their pair on the arch is missing)
- baby teeth (to make way for the permanent teeth underneath)
Obviously, if certain teeth have root canals, large fillings, and are overall unhealthy, they’re the prime candidates for orthodontic extraction, even if the case would call for a neighboring tooth to be removed. Your orthodontist will make it work, even if it’s not ideal.
Getting braces before extractions – is it normal?
If you’re reading this article in preparation for your extraction, you’re probably wondering why your doctor bonded braces before getting your teeth pulled. Why waste good brackets on teeth that will be gone in a few weeks or months?
Well, there’s actually a good reason behind it, and it’s meant to help your extraction go smoothly. Here’s what I mean:
- During the first weeks of braces, certain cells inside your bone will activate, causing teeth to move and become loose.
- Extracting a tooth that’s a little loose is far easier than extracting a normal tooth that never had braces on.
- The goal is to make the orthodontic extraction as non-traumatic as possible for the bone.
- The bone that’s left after the extraction will serve as a medium through which the neighboring teeth will move.
- If the bone is damaged and broken, tooth movement may take much longer, so we want extractions to be as gentle as possible.
Typically, it’s premolars that will benefit when getting pulled later rather than sooner. It can take anything from a few weeks to a few months after getting braces to get your premolars finally removed.
Another situation where your orthodontist might delay premolar extractions is reaching the right wire. Your orthodontist might want to start retraction mechanics (pulling your teeth back) right away after extractions, as fresh bone is always better for closing spaces than old extraction sites. But for this, he/she may need to reach a certain wire, and that may take a while.
How does pulling teeth with braces on work?
If your premolars are engaged in the wire, your orthodontist will see you before your appointment with the oral surgeon. Your archwire, ligatures, elastic ties – everything but the brackets – will be removed temporarily to make the surgeon’s job easier.
Your oral surgeon will pull one or both of your premolars just like they would a normal tooth, and you’ll be back in the orthodontist’s office as soon as possible, to get your wires back on.
Another option would be sectioning the wire and freeing the teeth that are about to get extracted, in which case you won’t have to visit your orthodontist immediately after your intervention.
What about pulling wisdom teeth with braces on?
Pulling wisdom teeth, supernumerary teeth, and baby teeth should preferably be done before bonding braces, just because these teeth aren’t affected by braces and won’t benefit from the ‘loosening’ effect.
Wisdom teeth extractions are known to be difficult and do come with risks, with or without braces. But if your surgeon’s instrument slips or they press too hard, some of the braces might come off. It’s an inconvenience, for sure, but it’s not a problem your orthodontist can’t fix.
All that matters after a 3rd molar removal is that you’re comfortable while healing. Braces come with added discomfort, and they take some getting used to, so it’s best to leave them for later.
That being said, overbooked surgeons and overbooked orthodontists don’t always mix well together, so you might not get the perfect timing for your braces and extractions.
Unexpected extractions – can the orthodontist change their mind?
What if you never discussed extractions when first getting started with braces, but now your orthodontist is pushing them as the better treatment plan?
Your orthodontist may not have had the best plan in place or the best communication. It’s not easy to decide on the best treatment option when a case is particularly challenging. Perhaps your teeth have shifted in ways that negatively impact the bite and facial esthetics, and it’s visible to you too.
Staying flexible and open to a new treatment plan is sometimes better than accepting a compromise, although it’s best to avoid this situation in the first place. It’s never too late to extract teeth, even after a couple of years with braces. It will add at least a year to your treatment, but it might be worth it.
Getting your teeth pulled, either before or after getting braces, is not a pleasant experience, we know. And we wouldn’t want to add any uncertainty or unease about this course of treatment. Hopefully, you’ve been properly briefed and understand why extractions are necessary. All you have to do now is trust your doctors and their recommendations.