Braces/orthodontics to close UL6 first molar extraction gap?

[JamesH]

I’m 42 and currently have all my adult teeth. I have a few composite fillings but have had no dental work other than that, so the prospect of losing a tooth, and an important one at that, is pretty daunting.

A CBCT scan has revealed a cracked root in my UL6 (first molar), with extensive external root resorption, which apparently means the tooth is unrestorable. The tooth isn’t causing me any pain but I’ve been told that it needs to be extracted.

The obvious treatment option is to have an implant (a bone graft would be needed at the extraction site for this due to the bone loss).

But coincidentally, shortly before discovering the UL6 issue I had an orthodontist consultation with a view to correcting moderate crowding and an upper midline shift to the right-hand side.

After hearing that I was considering orthodontic treatment, the specialist who diagnosed the UL6 problem (who actually offers implants) recommended closing the gap left by the UL6 extraction with braces, and felt this was a better solution than an implant.

I’ve seen two orthodontists to get their opinion about closing the post-extraction UL6 gap, and have had two very different opinions/recommendations:

Orthodontist 1:

Told me the space could be closed by moving UL7 (the second molar) forward into roughly half the space that will be left by the UL6 extraction, with the other half space filled by correcting the midline shift, which means moving my front teeth, canine, premolars, etc, over to the left.

I asked about moving my UL8 (wisdom tooth) forward as well – as otherwise there would be a new space created between UL7 and UL8 – and was told it might be possible but that it would be more difficult to move this tooth than it would UL7.

I was told the treatment time would be approx. 2 to 2.5 years.

Orthodontist 2:

Told me the above (treatment recommendation outlined by orthodontist 1) was possible but that at the end of treatment my front teeth "wouldn’t look right" (I think maybe due to creating another midline shift) unless they also extracted a healthy tooth on the upper right, which obviously I want to avoid.

Instead, their recommendation was to leave the gap left by the UL6 extraction and correct the crowding/midline shift by moving the teeth forward without further extractions and using only about 1mm of space left by the UL6 extraction. (Estimated treatment time for this would be 1 to 1.5 years).

In their view, after treatment, it would be fine for me to leave the gap caused by the UL6 extraction or, if I wanted, to have an implant in the space. But they said there were no issues with just leaving a gap.

However, orthodontist 1 has advised against leaving a gap after the UL6 extraction because of "unstable occlusion and bone loss to the area" and because it is "unnecessary when UL7 could provide good occlusion for the mandibular antagonists".

Confusion

I'm really confused by the two differing opinions and not sure who to believe. Both orthodontists have orthodontic masters degrees and plenty of experience.

Has anyone on here, as an adult, tried closing a gap left by a molar extraction via braces? If so, did it work? Were there any problems?

Would also be great to hear the views/thoughts of any orthodontists or dentists if poss.

My teeth and gums (apart from the UL6 tooth) are generally in pretty good health/condition and my original enquiry about getting braces was for cosmetic reasons to improve the appearance of the front teeth.

Many thanks

 

[MattKW]

1. Either recommendation (if possible) is still going to leave a gap. You might find this irritating.
2. Your front teeth are fully settled into their "happy" position. Any ortho changes are likely to upset this balance and require long-term use of a fixed or removable retainer. Do you want this nuisance? Did the orthos advise you of this?
3. The chewing surface anatomy of a 7 is different to that of a 6. This could upset your chewing comfort and cause you occlusal issues (pain on chewing, cusp cracks). If this happens, you could get around it by crowning the 7 to make it "fit"the opposing 6, but this raises other risks.
4. I suggest you leave the gap and save for an implant. There is a possibility that if the gap is left too long, the 8 may push the 7 forward, but tip it over. If the 8 has no opposing tooth with which to chew, I would consider extracting the 8.
5. Put up an OPG Xray if you have it available.

 

[JamesH]

1. Either recommendation (if possible) is still going to leave a gap. You might find this irritating.
2. Your front teeth are fully settled into their "happy" position. Any ortho changes are likely to upset this balance and require long-term use of a fixed or removable retainer. Do you want this nuisance? Did the orthos advise you of this?
3. The chewing surface anatomy of a 7 is different to that of a 6. This could upset your chewing comfort and cause you occlusal issues (pain on chewing, cusp cracks). If this happens, you could get around it by crowning the 7 to make it "fit"the opposing 6, but this raises other risks.
4. I suggest you leave the gap and save for an implant. There is a possibility that if the gap is left too long, the 8 may push the 7 forward, but tip it over. If the 8 has no opposing tooth with which to chew, I would consider extracting the 8.
5. Put up an OPG Xray if you have it available.

Really appreciate your reply, Matt. Thank you.

There seem to be potential risks/issues with every option. It would mean dipping into savings but I can afford an implant. The specialist who diagnosed the UL6 tooth issue (and offers implants, so would benefit financially from ‘selling’ me one) for some reason felt closing the gap orthodontically was a better option for me. They pointed out the need for constant meticulous cleaning around the implant and that there’s a raised risk of gum disease in the area.

Thanks for raising the point about the chewing surface anatomy of a 7 being different to that of a 6 and the problems that may pose (neither ortho mentioned this).

Here is a recent OPG x-ray: https://photos.app.goo.gl/2EFikk5wexSMc9Ho6

Any thoughts/suggestions you may have after seeing the OPG would be gratefully received.

Retainer/Ortho treatment

Re: the need for a fixed or removable retainer. Yes, both orthos advised this. I could opt for a removable retainer at night only, but they both said having a fixed retainer as well is the best way to minimise the chances of the teeth moving/returning to their old position post-treatment.

From what I’ve read, and please correct me if I’m wrong, people generally get used to using a retainer, and over time it may be possible to reduce wearing to every other night. The continued use of a retainer (providing it isn’t uncomfortable) seems like an okay trade-off for straight front teeth.

I’ve been told, due to signs of wear, that I probably grind my teeth in my sleep and that it would be a good idea to get a mouth guard (which I’m going to look into), so I guess a removable orthodontic retainer would do a similar job – with a similar nuisance factor – to a mouth guard, which it seems I need anyway.

Also, I have some uneven wear on the edges of my upper central incisors that I’m told is caused by my bite and, as things stand, will get worse over time. So aside from the cosmetic reasons, I believe ortho treatment should be able to halt this problem and the edges then restored with composite bonding.

 

[MattKW]

Thanks for info and OPG.

1. I haven't had many patients successfully wear removable retainers for the rest of their lives from my orthodontists for a long time, most eventually find it a nuisance.
2. Uneven wear on your incisors is difficult to comment upon without a photo and examination. However, you have all your teeth present, and some minimal wear is expected over a lifetime. I'm 64 and mine aren't the same as 16yo, but orthodontic treatment to somehow "prevent" further wear is wishful thinking. I have seen many strange bites over the years that work quite happily, and it's a brave dentist who wants to start defying Mother Nature.
3. I have seen the results of orthodontists trying to move molars forward, and I have yet to see a case where they really put in the effort and managed to keep a molar perfectly upright; the roots on your 2nd molars are long. If the molars are not upright after treatment, you won't be able to clean as easily as you can now, and decay follows; I really don't like the risk. If the orthodontists can show you similar cases they have treated successfully, then maybe I'm wrong.
4. On the good side, you have good bone thickness around your molar. Even after extraction, I think you'd be a good candidate for an implant.
5. I'd still go for simultaneous extraction of the 1st and 3rd molars, then implant later.
6. So, you have lots of conflicting suggestions, and this is a big decision. Maybe go see a specialist prosthodontist for another opinion. Take along my comments. Keep in touch. Cheers.

 

[JamesH]

Thanks for info and OPG.

1. I haven't had many patients successfully wear removable retainers for the rest of their lives from my orthodontists for a long time, most eventually find it a nuisance.
2. Uneven wear on your incisors is difficult to comment upon without a photo and examination. However, you have all your teeth present, and some minimal wear is expected over a lifetime. I'm 64 and mine aren't the same as 16yo, but orthodontic treatment to somehow "prevent" further wear is wishful thinking. I have seen many strange bites over the years that work quite happily, and it's a brave dentist who wants to start defying Mother Nature.
3. I have seen the results of orthodontists trying to move molars forward, and I have yet to see a case where they really put in the effort and managed to keep a molar perfectly upright; the roots on your 2nd molars are long. If the molars are not upright after treatment, you won't be able to clean as easily as you can now, and decay follows; I really don't like the risk. If the orthodontists can show you similar cases they have treated successfully, then maybe I'm wrong.
4. On the good side, you have good bone thickness around your molar. Even after extraction, I think you'd be a good candidate for an implant.
5. I'd still go for simultaneous extraction of the 1st and 3rd molars, then implant later.
6. So, you have lots of conflicting suggestions, and this is a big decision. Maybe go see a specialist prosthodontist for another opinion. Take along my comments. Keep in touch. Cheers.

Thanks again, Matt, for the info and insight. It sounds like you have a lot of experience of seeing how the dental decisions people make turn out for them in the long-term.

Regarding the uneven wear on the incisors, here are some photos:

Front 1:

https://photos.app.goo.gl/y3mXEEhhQ1wx1c2M8

Front 2:

https://photos.app.goo.gl/aJrup1BDRo8CLFfa9

Left side:

https://photos.app.goo.gl/q3BGrTNbqrMeGzKx8

Right side:

https://photos.app.goo.gl/o7RQT6WbYyJpc9Gc8

I guess, as things stand, the incisors would most likely continue to function without causing me problems for a good many years, but I presume that as the uneven wear continues, the teeth will look increasingly unsightly (although obviously there are far worse things in life than worn/crooked teeth).

It sounds like I might need to reconsider moving the UL7 into the UL6 space, and perhaps go the implant route instead. I’d been told that I’ve lost a fair amount of bone around the UL6. Perhaps that only shows up on the CBCT scan. Here is a CBCT image of the area:

https://photos.app.goo.gl/66pfKEmQrWLmVKFx9

If I opted for an implant in the space after extraction of UL6 and also went ahead with ortho to straighten//improve the appearance of the front teeth, would it be okay to have these two treatments more or less concurrently? Or is it best to have the implant first, then do the orthodontics later? Or do the orthodontics first and then the implant after the brace has come off perhaps two years or so down the line?

Would you recommend extracting UL8 in any case or is that just if I plan to leave an unfilled UL6 gap for a long period of time?

Sorry for all the questions. I greatly appreciate all the thoughts and insight you’ve given me already, and totally understand if you don’t have time to answer them all.

 

[MattKW]

Thanks for all the pics. Hmm... interesting!

1. It'll be interesting to see what difference the ortho treatment makes to your front teeth. I'm no ortho, but that looks challenging. Looks like a Class II div 2, usually best addressed in the teenage years. Have they given to a print-out of what they think it'll look like at the end?
2. I would have the ortho done first. Once you put in an implant, you can't change the position. This is more of an issue for anterior implants, but yeah, I'd avoid the implant for now. The orthodontist can keep the space open.
3. Leave the 18 in place during ortho treatment. It might be useful as anchorage for the ortho treatment.
4. Once the ortho treatment is completed, and the implant has been placed, get rid of the 18. It probably doesn't contact much on the lower (maybe a bit of the lower 7 because of 1. above?), but they are difficult to keep clean for the rest of your life (90+?) and there is an unnecessary risk of developing either decay in the 8 itself, or decay in the back of the adjacent 7.

 

[JamesH]

I would suggest seeking a third opinion from a trusted orthodontist or even a dentist who specializes in implantology. They can give you a more comprehensive and impartial perspective on your situation.

Thank you. Yes, that's a good idea. I've seen a couple of orthodontists and a couple of restorative dentists with slightly different specialisms. Trouble is that each of them has a vested financial interest, so they aren't really impartial.

 

[JamesH]

Thanks for all the pics. Hmm... interesting!

1. It'll be interesting to see what difference the ortho treatment makes to your front teeth. I'm no ortho, but that looks challenging. Looks like a Class II div 2, usually best addressed in the teenage years. Have they given to a print-out of what they think it'll look like at the end?
2. I would have the ortho done first. Once you put in an implant, you can't change the position. This is more of an issue for anterior implants, but yeah, I'd avoid the implant for now. The orthodontist can keep the space open.
3. Leave the 18 in place during ortho treatment. It might be useful as anchorage for the ortho treatment.
4. Once the ortho treatment is completed, and the implant has been placed, get rid of the 18. It probably doesn't contact much on the lower (maybe a bit of the lower 7 because of 1. above?), but they are difficult to keep clean for the rest of your life (90+?) and there is an unnecessary risk of developing either decay in the 8 itself, or decay in the back of the adjacent 7.

Thanks again, Matt. That’s really useful.

Is it advisable to get a bone graft at the UL6 extraction site at the time of extraction if I have ortho treatment first and delay the implant by, say, two years or so?

Just wondering, as I’ve read/been told different things about this. Some that it’s only worth getting a bone graft a short time before an implant is placed, others that it’s best to get a bone graft at the time of extraction to help preserve bone and gum, even if deferring an implant for a longish time.

No, they haven’t given me a printout or shown me what the teeth are likely to look like after treatment. Both orthodontists seemed confident the front teeth could be straightened, and the ortho who advised against trying to close the gap said the front teeth issue is ‘pretty easy to sort out’ with 12 to 18 months in braces.

Class II div 2, yes, you’re absolutely right. Here is the finding of the ortho who took the OPG (not that I fully understand all of the wording):

“He presents with a class II, division II incisor relationship on a skeletal II base with a reduced maxillary mandibular plane angle. The overjet is positive at 1mm and the overbite is increased and complete. There is moderate crowding in the upper arch and mild crowding in the lower arch. The upper centre line has displaced to the right and the lower centre line has displaced to the left. The molar relationship on the left is a full unit class II and on the right the molar relationship is class I. The x-rays show that the upper and lower incisors are retroclined and he has a horizontal impacted lower left wisdom tooth.”

 

[MattKW]

Oh, didn't you get my consultation fee by email?

 

[JamesH]

Oh, didn't you get my consultation fee by email?

Haha, you’ve been super helpful and clear with all the advice/suggestions! Really do appreciate it.

Definitely feel I owe you a beer, or non-alcoholic drink, if you’re ever in the UK!

I’ve replied to your last message (thanks again), but it’s awaiting moderator approval.