One very common question on our Metal Mouth Forum involves extraction. Often, adults may need teeth extracted to make room so their other teeth can move into their proper positions. It's so easy for someone else to tell you that you need teeth removed. After all, the teeth are not coming from their mouth! And as you know, after teeth are removed, you can't put them back. It's the permanence of the procedure that makes this a very difficult decision for adults.

Let me tell you my story. My teeth were never perfectly straight, and they got more crooked as I got older (despite 4 impacted wisdom teeth being removed in my early 20s). By my early 30s I wanted braces, but every orthodontist that I saw (and I saw plenty) told me that I needed 4 teeth extracted. Well, I didn't like that one bit. In fact, I was totally against it. So I just resolved to live with crooked teeth.

Fast forward 10 years. Here I am, at age 43 in braces, with a near-perfect smile, which was only achieved by -- you guessed it -- extracting 4 second bicuspids. Boy, do I wish I'd had this done 10 years ago. Now I feel really silly for being so scared and waiting so long.

The orthodontist who finally treated me tried very hard to fix my teeth without extracting, but it just didn't work. (I applaud his earnest efforts on my behalf). Six months into treatment, it was evident to me (and to him), that the extractions were necessary. At this point I felt better about it because at least we had TRIED the other way. 

Was I remorseful about losing those perfectly healthy teeth for the sake of beauty? Yes, of course I was! I felt sick about it! After the extraction, I kept thinking, "Oh God, have I done the right thing?" But soon I got over it. Now that the extraction gaps have closed and my smile looks great, I know I made the right decision. I was worried that extracting teeth would negatively impact my facial aesthetics (which, IMO, didn't need any changing). But you know what? The change is very subtle, and in fact, it is actually good. 

But that is my experience and it may not be the same as your experience. Sometimes if the mouth and smile are already "small," depending on your facial bone structure, extractions may result in your face looking "sunken in" over time because the underlying structure has been changed. Before you decide on extractions, you should get several opinions, ask how your facial aesthetics may change, and think about it carefully. In some cases, other methods can be used to make space, such as "shaving" the teeth or using Damon-type brackets (whose manufacturer claims that they eliminate the need for extraction in some patients). This orthodontist's web page talks a little bit about why he feels Damon brackets help eliminate some extractions. As time goes on, there may be other methods developed which also help to reduce the need for extractions.

If you want to read a detailed account of what my extractions felt like, click here.

If you are hanging on the fence, not sure what to do, then this article will give you some information to help you decide the best course of action.

Why are Extractions Necessary?

By the time we are adults, our jaws have stopped growing. Sometimes our palate can be expanded, but other than that, there is limited room for improvement. If your teeth are crowded, you may need to have some of them taken out to make room for the other teeth to move into better positions. Usually an orthodontist will start with the wisdom teeth. If there still isn't enough room, the back bicuspids are usually chosen next. Because your smile must be symmetrical, the same teeth usually must be taken from the top and the bottom. If two teeth are taken from one side, your midline (the place where your front top and bottom teeth meet) may be thrown off, and you may be stuck with a crooked smile. This is why teeth are often extracted in either 2s or (more commonly) 4s.

Extractions and Children: Be Careful!

What about children? Personally I do not advocate tooth extraction in children because they are still growing. Years ago, extraction for children was common, but this is not the case today. Some orthodontists still routinely extract children's teeth. If you encounter this, please seek several additional opinions before making your decision.

There are many other methods that can be used to meld children's jaws to make room (palate expansion, headgear, or guided growth methodology). Extracting teeth from children can result in less than optimal facial aesthetics. In other words, you child's face may not wind up looking as good as it could have, because it will grow longer and flatter instead of fuller. 

One exception involves a Class III malocclusion. Class III cases are technically much more difficult and often involve jaw surgery. If you need more information about Class III malocclusion, read about it in our FAQ.

Who Performs the Extraction?

Usually an oral surgeon extracts teeth. Other types of dental professionals with training in tooth extraction may also perform the procedure.

Does Extraction Hurt?

Extraction of wisdom teeth is quite involved, with sedation, stitches, pain, possible bruising, and inconvenience. 

Extraction of bicuspids and other teeth is a piece of cake compared to wisdom teeth. There is virtually no pain afterwards (yes, I know that's hard to believe, but it's true). You can either get local anesthetic or get "put out" for the procedure. It takes only about 20 minutes total to extract four bicuspids! There is usually no stitches, very little bleeding, and usually no bruising. [Please do not take any anti-inflammatory or pain medicines beforehand -- they prevent clotting, which could result in more bleeding. So, take no Advil (ibuprofen), no Tylenol (acetaminophen), and no aspirin beforehand! If you take a regular dose of an anti-inflammatory medication for arthritis or other chronic condition, tell your dentist!] 

Afterwards, the oral surgeon will give you some strong prescription pain pills such as Vicodin. In my  case, I had so little pain that I took only one when I got home (as a precaution), but didn't need any more than that! By the way, I have a relatively low pain threshold -- so you see, it barely hurt at all! You will be told to eat soft food and not to suck on straws for several days. After that, you can do whatever you want.

Can There be Complications?

It is rare, but sometimes complications can result from tooth extractions. If the hole doesn't heal properly, you may develop what is known as a dry socket, which may get infected. The following information comes from the website Ask an Oral & Maxillofacial Surgeon.

"A dry socket occurs when the blood clot is lost from an extraction site prematurely. Basically, the blood clot in the socket serves the same two functions as a "scab" on a skin surface cut. First, it assists in the cessation of bleeding and second, it protects underlying structures during the healing process. Like the child who "picks at a scab" the area heals in time but is painful for far longer than if the "scab" had been left alone.

"When the blood clot is lost before the underlying structures have had time to heal, bone is exposed to the oral environment along with fine nerve endings. This is an exquisitely painful but otherwise relatively harmless situation. There are packing materials which the oral surgeon can place to help ease the discomfort both by physically blocking the wound and by the action of the chemicals in the pack on local nerve endings. Generally, patients return to have the pack changed every day or two and most patients do not require more than 2 or three dressing changes. Some patients require no dressing while others may require 4 or 5 changes of packing. Tincture of time and good oral hygiene usually resolve the situation.

"There are some activities which may increase the propensity for dry socket formation...smoking, drinking carbonated beverages in the first 24 hours after surgery, spitting or drinking through a straw in that same time period...but often "dry sockets" occur for no particular reason at all."

When Are The Braces Put On?

After an extraction, braces can be put on almost immediately. (I already had braces, so my arch wires were taken off first. After the extractions, the arch wires were replaced the following week).

What About Eating and Talking?

Yes, eating with several gaps in your mouth is very strange. Be sure to take small bites and chew slowly and carefully. You will need to change the way you chew for a while, until the gaps begin to close. Food may get stuck in gaps, which is annoying. 

As time passes and the gaps close, this will become less of a problem. Just hang in there and deal with it. Also remember that your bite will change as time passes, so your teeth will meet differently, and you will chew differently as you go through the stages of gap closure and teeth straightening.

If frontal teeth have been extracted, you will have to deal with other people noticing your gaps. Yes, this can be a bit embarrassing, but remember that it is only temporary. In a few months, the gaps will be gone (particularly the top gaps, which tend to close more quickly).

How Long Does It Take to Close The Gaps?

The length of time to close extraction gaps depends on your unique case. But the short answer is: between 4 months and one year. 

The gaps on top often close faster than those on the bottom. My orthodontist said that typically the teeth move about one millimeter per month. Your orthodontist may use power chains or other methods of linking the teeth together to close the gaps. 

It took 21 months to completely close all of my extraction gaps (I needed closing loops, as shown in the next section), but I am an exception -- I had a couple of stubborn lower teeth! In fact, the top gaps closed within 9 months. 

Each month, your orthodontist can measure the gaps between your teeth with a special ruler. By doing this, you can see solid results from month to month. This is a  good idea, because at first it will seem like your teeth aren't moving at all -- when in fact, they are!

Here's a photo of my teeth after the gaps on both top and bottom were completely closed. You'd never know that I had two teeth extracted on the bottom, and two on the top!

How Do They Close The Gaps?

Extraction gaps are usually closed with power chains or other special methods of linking teeth together. White power chain is shown linking my teeth in the photo on the left. Notice the extraction gap between the molar and the bicuspid. The power chain is attached to the hooks on some brackets, and also put directly on the brackets in place of ligatures. (I don't recommend white color power chains, because they show a lot of stains. I've had great success with "smoke" grey color, which is almost invisible. Smoke-colored chains are on the top teeth in the large photo below. Notice that you can barely see them! They "resist" curry stains quite well.)

In some cases, the orthodontist makes a loop in the arch wire to close the gaps. This is sometimes called a "finishing loop"  or "closing loop" because it is usually done near the end of treatment to help close stubborn gaps that are not helped by other methods.

Arch Wire Displacement (otherwise know as "a poking wire")

When extraction gaps are closing, the arch wire will often be displaced and the "extra" bit will poke into the end at your cheek. This is very common, and it hurts like hell! If this happens to you, do not wait -- call your orthodontist immediately to get the wire trimmed! You  can temporarily remedy the situation by globbing some wax or chewing gum at the end of the wire (but this frankly doesn't work very well). Sometimes, teeth move "all of a sudden" and you find yourself making an emergency trip to your orthodontist to have the wire trimmed. You can purchase a pair of orthodontic pliers for emergency clippings -- but personally my husband was afraid to even try to clip the end of my wires (and you can't really do it on yourself).

Although arch wire displacement is literally a big pain, it is positive. It means that your teeth are moving and the gaps are closing!

What Do Others Say?

Here are some comments from readers of our Metal Mouth Forum regarding extractions:

"In December 2003, I had 2 upper bicuspids extracted. I went to my appointment directly from work late in the morning. The extractions themselves were quick and painless and I had very little bleeding. I was back at work after my half hour drive home. Later that day after the numbing medication wore off, I did not have any pain or bleeding.

The worst part for me was the time I wasted worrying about the whole procedure. For three weeks, I was in a total panic about the extractions. I was afraid and expected the worst. But it was really no big deal. Hope your extractions go as well as mine did. Good luck."

[editor's note: Unless you absolutely positively need to go right back to work or school, it would be better to take the rest of the day off. Go home and take it easy!]

*****

"I had to have 2 back teeth extracted 2 months ago. I went in at 7:30 in the morning and went to work after it was done. And these teeth were difficult to pull--not as bad as impacted wisdom teeth, but not as easy as other teeth. The main problem was feeling this gap where my teeth once were.

I took one Vicodin tablet that night, but managed on OTC pain meds during the day. The next day it was fine.

Hang in there!"

*****

"I second the opinion that worrying about the extractions (& braces) was worse than the actual event. Relatively painless, however, be prepared for a liquid diet for at least a few days."

*****

"I had braces put on on the Monday and 4 teeth extracted on the Thursday and was not back to work until the following Tuesday. I somehow developed dry socket in two of my four gaps!!! It was extremely painful. I followed Dr orders to a T, but I guess I wasn't so lucky! Sounds like this is pretty rare though, so I wouldn't worry."