Tooth extraction and IPR

Question 1

Do all my wisdom teeth have to be removed before I start treatment?

Accepted Answer

Wisdom teeth do not always get in the way of orthodontic treatment, and you do not need to have them taken out before the consultation. In some cases they may need to be removed at a later stage, but there are also situations where the wisdom teeth are healthy and functional, which means they can stay in the mouth. If your general dentist recommends removing them, you can go ahead, but this does not need to happen before the orthodontic consultation. In some cases a missing tooth can be replaced by a wisdom tooth, if the wisdom tooth's position allows it to be moved into line.

Question 2

I've had different opinions at consultations – treatment with extractions and treatment without. Which should I choose?

Accepted Answer

Every orthodontic case is unique, and there may be more than one correct solution. The best approach is to put your trust in a specialist who can convince you of the treatment plan they are proposing. If you come across significant differences between the opinions of different orthodontists, it is well worth seeking further consultations. Taking out teeth is irreversible, so you should be given clear reasons why it is necessary. Differing opinions may come down to the specialists' different approaches and experience. It is important to weigh up the pros and cons of each proposal, taking into account the scientific evidence and the latest developments in orthodontics.

Question 3

Which is better – having wisdom teeth or premolars taken out?

Accepted Answer

There is no one-size-fits-all answer to this question. Wisdom teeth sit at the very back of the dental arch, and the space they free up is often too far from the area that needs it. If there is a significant lack of space for the front teeth, removing only the wisdom teeth is sometimes not enough, and premolars may need to be removed as well. If the problem can be solved by removing only the wisdom teeth, that is the better option. Orthodontics has many techniques and tools that make it possible to achieve almost any tooth movement.

Question 4

What is stripping (IPR)?

Accepted Answer

Stripping (interproximal reduction, IPR) is a procedure in which a small amount of enamel is carefully filed away from the sides of the teeth to create space for aligning them. It is most often used on teeth that are wider or triangular in shape, particularly the lower front incisors. The amount of enamel removed is minimal and does not affect the strength of the tooth. IPR can be used in two main situations – when the lack of space for aligning the teeth is slight, or when the shape of the teeth needs to be corrected to reduce the gaps between them.

Question 5

Will stripping (IPR) damage my teeth?

Accepted Answer

If the procedure is carried out correctly, there is no danger of the teeth being damaged. The amount of enamel removed is minimal – just fractions of a millimetre. For each group of teeth there is a set maximum amount that can be removed, and this must not be exceeded. Orthodontists use special measuring instruments to control the process. When the rules of stripping (interproximal reduction, IPR) are followed, there is no risk of decay or damage to the teeth.

Question 6

Will stripping leave gaps between my teeth?

Accepted Answer

Because the amount of enamel removed is extremely small, in most cases no visible gaps form between the teeth. The appearance and size of the teeth stay almost the same. There may be a slight change in shape – for example, the teeth may look more rectangular, if that is the aim of the procedure. Even so, when stripping (interproximal reduction, IPR) is done correctly, it does not noticeably change how the teeth look.

Question 7

How do I choose between treatment with stripping and treatment with extractions?

Accepted Answer

If, after your case has been assessed, you are offered more than one possible treatment option, the most important thing is to weigh up the pros and cons of each. If you do not have enough information, it is a good idea to talk the situation through with your orthodontist. For example, a patient with a moderate lack of space for her teeth, a correct bite and slightly protruding teeth has to choose between two options – stripping (interproximal reduction, IPR) or having four premolars taken out. With the first option, the space needed to align the teeth is created by slightly widening the dental arch and carrying out the maximum permissible amount of stripping. The drawbacks of this approach are that it removes some enamel and that it does not allow the teeth to be moved back, because the space created is only enough to align them. The advantage is that all the teeth are kept and treatment time is shorter. The second option involves taking out four premolars, which provides enough space not only to align the teeth but also to move them back. The drawbacks are that healthy teeth are removed and treatment takes longer. The choice between the two plans depends on the patient's personal preferences and the end result they are hoping for.

Question 8

Can we try to straighten my teeth without extractions and take teeth out during treatment if it turns out to be necessary?

Accepted Answer

Some clinical cases can be described as "borderline", meaning that treatment is possible either without or with extractions. If the orthodontist advises taking out some teeth to align the smile, but the patient is very worried about whether they're making the right decision, it's possible to start aligning the teeth without extractions and then, after a certain number of months of treatment, once it's clear that space inevitably has to be created, switch to a plan with extractions. This approach isn't suitable in every case. To start without extractions, we have to be sure that the movements that will happen during this assessment period won't put the health of the teeth and gums at risk. Also bear in mind that changing the treatment plan like this once treatment has already started makes it take longer.

Question 9

How soon after having a tooth out can I start treatment?

Accepted Answer

If a tooth has had to be extracted for orthodontic reasons, there is a healing period afterwards. How long it lasts can vary depending on the type and size of the tooth removed, the body's ability to heal, and whether there is any problem with contamination or inflammation of the wound. In general, it's advisable to fit an orthodontic appliance once the discomfort from the extraction has passed and the soft tissue has healed. For premolar extractions this means at least one week; after wisdom tooth removal it may be worth waiting more than two weeks. If you go ahead with extractions prescribed by your orthodontist, it's best for treatment to start soon afterwards – no more than 3 months should pass between the extractions and fitting the appliance. Of course, it's possible to start treatment later, but you'll lose the chance of faster initial tooth movement that comes when the extraction is recent.

Question 10

Is it normal to be advised to take out different teeth on each side (for example, the 4th on the right and the 5th on the left)? Will I lose symmetry?

Accepted Answer

The pattern of extractions for orthodontic reasons (when they're needed) can vary a great deal and is strictly individual. One reason we might extract different, non-matching teeth on the two sides is, for example, an asymmetrical bite. On the side where space is lacking much more, a tooth further forward is extracted (for example, the fourth), and on the side with less crowding, one further back (for example, the fifth). Another reason for asymmetrical extractions may be that on one side there is a completely healthy fourth tooth and a non-vital (root-treated) fifth tooth. In this case we will choose the fifth tooth, even if the fourth is better placed for solving the problem. If on the other side both premolars are equally healthy, we'll choose the one in the more suitable position for the treatment – for example, the fourth. The symmetry of the teeth will be preserved by carrying out the treatment plan correctly and distributing the space from the extracted teeth properly.

Question 11

Will my face change if I have teeth taken out?

Accepted Answer

Teeth are extracted for orthodontic treatment to make room for very crooked or protruding teeth, or to correct the bite. Changes that are part of the orthodontic plan – moving teeth back, for example – can change the appearance of the face. If the teeth protrude, moving them back will improve the appearance of the face; if the patient's profile doesn't stick forward, extractions should be avoided. Having your wisdom teeth out won't affect the soft-tissue profile of your face, unless the plan is to move all the teeth significantly backwards.

Question 12

When does treatment require taking out just one lower front tooth?

Accepted Answer

A patient may have well-aligned upper teeth, a correct bite in the side teeth and very crooked lower front teeth. This can be due to what's known as a tooth-size discrepancy. The combined width of the upper front teeth and the combined width of the lower front teeth should be in the right proportion. The deviation from this relationship can be so marked that one lower front tooth (an incisor) has to be removed to make room for aligning the lower front teeth, while keeping the bite – which was correct to begin with – unchanged.

Question 13

Which is better – moving the side teeth back to make room for the front ones, or taking out healthy teeth?

Accepted Answer

In some patients the teeth are so crowded and the jaw so small, among other factors, that healthy premolars have to be extracted. In other patients, moving the side teeth back to create space is entirely possible. The patient's diagnosis and needs point to which method is more suitable. If, after the orthodontic analysis, you face a choice between these two treatment options, you should weigh up the pros and cons – treatment time, the cost of the appliances, the expected final result (are there any differences?), and how stable the result will be over time.

Question 14

I need my wisdom teeth out before getting braces. What comes first – the impressions or the extractions?

Accepted Answer

At your consultation, you may have been told that you'll probably need to have your wisdom teeth out. The orthodontic analysis will confirm this, so I'd advise you to have the analysis done first, before having any teeth taken out. Sometimes wisdom teeth can be used for anchorage during orthodontic tooth movement, or the plan may be to align them in the arch.

Question 15

Is there an orthodontist who doesn't take teeth out?

Accepted Answer

The reason teeth sometimes need to be taken out as part of an orthodontic treatment plan is that there isn't enough room to fit all the teeth into a jaw that has stayed narrow as it grew. We can't always find room for all the permanent teeth in the mouth. Sometimes removing the wisdom teeth is enough to give us the space we need. In other cases, other teeth have to be removed – for example premolars – to make room for rotated front teeth, to correct the bite, or for so-called camouflage. Even if an orthodontist does everything they can to avoid extracting healthy permanent teeth from their patients' mouths, in certain cases this simply isn't possible.

Question 16

If my lower 6 (first molar) is missing, can the gap be closed by moving the other teeth together?

Accepted Answer

Molars are among the teeth most often affected by decay, so they often need treatment from an early age. Their early decay is sometimes the reason they have to be extracted in young patients. When we lose a single tooth, the best thing we can do is replace it with an implant. The implant is placed in the bone and isn't attached to the neighbouring teeth, so it doesn't harm them – unlike a bridge, for example, which requires grinding down healthy neighbouring teeth. If a single molar has been extracted and orthodontic treatment lies ahead, it makes sense to try to close the space left by the extracted tooth with the remaining teeth. For this to be possible, the wisdom tooth on the same side must have come through in the correct position, or an X-ray must show that it is correctly angled towards the dental arch. In that case, as the space closes, the prematurely lost tooth will be made up for by the other 2 permanent molars. If the wisdom tooth on the affected side of the same jaw isn't angled in the right direction or is missing, then we recommend replacing the extracted tooth with an implant. Bear in mind that closing the extraction space of such a tooth takes quite a long time. Treatment is expected to last between 2 and 3 years.

Question 17

Are braces put on wisdom teeth?

Accepted Answer

Placing a bracket on a wisdom tooth is possible if its position allows it and there is enough access to it. In some cases, the wisdom tooth is brought into line in the dental arch and can replace a missing tooth. However, if all the other teeth are present and no extractions are planned, wisdom teeth that have come through are not usually included in orthodontic treatment. In many cases it is even recommended to remove them to avoid future complications.

Question 18

If I need four premolars taken out, in what order are they removed? Can it be done all at once?

Accepted Answer

This is best discussed with your chosen oral surgeon. In some cases, surgeons go along with the patient's wishes and can extract all the planned teeth in one visit. This is done under local anaesthetic, with the patient remaining conscious. The main advantage of removing them all at once is that you recover from everything in one go, within a few days. On the other hand, this approach causes more discomfort after the procedure and makes eating harder, as there are wounds on both the left and right sides of the mouth. For this reason, surgeons usually recommend removing the teeth in stages – first two premolars (upper and lower) on one side, so that the patient can eat more easily. Once the discomfort from the first procedure has settled, usually after about a week, the remaining two teeth on the other side are removed.

Question 19

If I need premolars taken out, how is the space closed – do only the front teeth move back, or do the back teeth move forward too?

Accepted Answer

How the space from extracted teeth is shared out depends on how much room the remaining teeth in the arch need and on how far off the bite is. For example, if the front teeth clearly need a lot of room to line up, the whole space created by the extractions will probably be taken up by the front teeth alone. If premolars are taken out to correct the bite, the space may be closed by the front teeth, by the front and back teeth equally, or entirely by the back teeth, depending on what the bite needs. Planning how the space will be closed is one of the orthodontist's most important tasks.

Question 20

Can I have a wisdom tooth taken out during treatment with braces or aligners?

Accepted Answer

Braces usually aren't put on wisdom teeth. If that's the case for you, the wisdom tooth can safely be taken out during orthodontic treatment with braces or aligners. If the tooth does have a bracket on it but still needs to come out, you'll first need to see your orthodontist to have the bracket removed and the tooth freed from the archwire, so that the oral surgeon has access to extract it.

Question 21

When will the gaps from my extracted teeth close?

Accepted Answer

The spaces left by extracted teeth start closing as soon as the braces are fitted, but slowly. The main redistribution of space in the arch happens during the working phase of treatment. By then the archwires are stiff and thick enough to let the brackets slide along them towards each other, like on a rail, pulled by elastics or springs. The space left by extracted premolars is about 8 mm on average. The normal rate of space closure is about 1 mm a month.

Question 22

Will gaps open up between some of my teeth after my wisdom teeth are taken out?

Accepted Answer

Teeth are able to move on their own, without any orthodontic force being applied, whatever your age. The most common natural movement is all the teeth gradually moving forwards over the years under pressure from the tongue. If a single tooth is missing, you may notice the teeth next to the gap starting to move towards each other and tilt . This is due to the network of fibres in the gum that connects the teeth and pulls them towards each other. It is important to note that this natural movement does not happen with wisdom teeth . If a wisdom tooth is extracted, the other teeth will not move backwards, because there is nothing for them to be pulled towards. When teeth are moved backwards with orthodontic force (for example, to make use of the space freed up by an extracted wisdom tooth), gaps can appear between the teeth further forward . This is because this kind of movement usually happens in groups rather than one tooth at a time, which can lead to the space being distributed unevenly.

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