x4 Premolar extractions

Standard Toaster

Hi guys,

I'm due to get braces fitted in the next few weeks and I've to get 4 premolars removed first. Two on top and two on the bottem.

Maybe you can't answer this but what can I expect here? Are they normally difficult to extract? I guess everyone is different so maybe who can say?

Also, what can I expect to pay for 4 extractions? Can I expect these to be done all in one sitting?

Oddly enough, I'm not too nervous

Cheers guys.

kkth0360

Hi,
Premolar extractions for orthodontic treatment are usually fairly straightforward since the teeth are normally intact and easily accessible. You'll feel a bit of pushing and pressure, and hear some creaking or cracking noises (completely normal) and the tooth will be out in about 10 seconds or so.

Occasionally a little bit of the tip of the root will fracture off and be left behind - this is largely due to the root anatomy of these teeth, and very seldom causes any problem with the subsequent orthodontic work.

Often, a dentist will suggest doing the extractiions in 2 visits - upper and lower on one side first and then the other side a week or so later. This makes it more comfortable to eat after the extractions, and also avoids having your entire lower lip and tongue numb from the anaesthetic if both sides are done together.

Not sure about the cost - I'd guess around €200-€300 for 4 simple extractions, but perhaps one of the General Dentists will correct me on this?

Best of luck

carrickmilo

Don't do it. Get a second opinion.

I had this done to me as a teenager and in my 40s developed TMJ dysfunction. Most of the patients he treats are either whiplash injuries or people who had 4 pre-molars removed for braces. In both cases the disc becomes dislocated.

We were designed to have 32 teeth. A good orthodontist can expand your dental arch instead.

I am so angry to hear they are still suggesting this

ballsymchugh

unfortunately for the kind of expansion that's neccessary in some cases, you need to start treatment at between 7 and 9 years old, as the lower jaw can be difficult to expand in later life.
is there any research linking tmj dysfunction and premolar extraction?? tmj dysfunction is hazy at the best of times.
and unfortunately we are being redesigned to have less than 32 teeth, hence the relatively high amount of people that have wisdom teeth extractions because they don't have the space. it all started 45000 years ago when man started cooking food instead of chewing the bejaysis out of raw meat.

as for the original questions, premolar extractions are pretty easy, complications are very rare, and as kkth said, should be about 200yoyo. as for getting them all done in one go, it's up to you and how brave you are. but it is more comfortable to do it one side at a time.

carrickmilo

For a proper specialist TMJ dysfunction is not hazy.

X-rays and tomographs taken from precise viewpoints can image the position of the condyles in the fossa very well and shown up any malpositioning, mainly when they are too far up and back and therfore occupying the freeway space where the disc and retrodiscal tissue should be. MRI images shown soft tissue pathology specifically disc displacement, the classic scenario is anterior, towards the front of the condyle which produces the clicking sound and causes the masticatory muscles to go into spasm.

The bone of the both the upper and lower jaw is chemically different from the other bones in the body, dermal not chrondral and has remodelling potential which is why adult orthodontics are possible.

ballsymchugh

sorry, you're right, but a proper tmj specialist can be hard to find. when you have oral surgeons and restorative dentists arguing over the best way to treat, and specialists that send you to sleep (back in college days anyway!) it's the treatment that's a tad hazy, unless you go surgical straight away to correct the positioning of the disc.

by the way, have you any idea what the link between premolar extraction and tmj dysfunction may be??
an interesting site that's been lambasted by his peers is john mew's, check www.orthotropics.com
he's more concerned with changing the appearance of the face, rather than straightening the teeth though. but he very rarely works on adults.
conventional adult ortho is possible, but the risk of relapse is greater. hence the lovely fixed retainers.

carrickmilo

Yes specialists are hard to find in Ireland but I have since found that there are a handful. I had to go to the US for treatment and in spite of wearing a pivot appliance for 15 months had to have the discs surgically repositioned in the end.

I now have a new bite and a new face, its longer, the chin is more prominent, the overworked masseter muscles have reduced to normal size and I can see my cheekbones again. Also clicking and deviation on opening have stopped.

I'm not sure exactly why there seems to be a correlation between pre-molar extraction and the development of TMJ dysfunction.
Speculatively it could be caused by one of two things:
as a contributing factor to the loss of vertical dimension and/or trapping the mandible too far behind interiorly inclined upper anterior teeth.

I have the feeling that fully formed dental arches provide the best anatomical framework for the TMJs. Why mess with nature?

carrickmilo

Posted twice

ballsymchugh

unfortunately it's nature messing with the tmj!!
if you ask any orthodontist what the cause of overcrowding is they will say genetics, although after doing a course with john mew i would think it's more to do with habit (i can't think of the right term now, it's where the environment affects development!!).
if you go to the website i posted earlier, there's a pretty interesting video about half way down about how development in some patients has to be guided.
sounds like you had a hell of a time, good to see it turned out well. it's a pity you had to go to the usa to sort it out though. at least you paid attention and can tell the tale better than most. thanks!!

kkth0360

The relationship between occlusion, orthodontic treatment and TMJ dysfunction is somewhat controversial. It has been claimed that premolar extractions can lead to over-retraction of the anterior teeth, forcing the condyles posteriorly and giving rise to problems within the joint, and it has also been suggested that extractions cause a collapse in vertical dimension leading to TMJ pathology.

However when the substantial body of scientific evidence on this subject is examined, these claims are found to have no basis in fact:

A recent, high-quality systematic review of the literature (the highest level of scientific evidence) concluded that there was “no support for the belief that orthodontic treatment may cause TMD”, and numerous studies specifically evaluating the relationships of premolar extractions to incidence of TMD signs and symptoms, disc position and other parameters have failed to find any correlation.

For those of us who strive to treat our patients to the highest possible standard, and in accordance with the best available published, peer-reviewed evidence, the answer is clear: premolar extractions, judiciously prescribed as part of a treatment plan based on sound diagnostic principles, will not predispose our patients to developing TMJ problems later.

Having said that, it is true to say that most orthodontists are carrying out more non-extraction treatment now than ever before, in both adults and children. This is due in large part to the ever-increasing evidence that extraction treatment does not guarantee long-term stability and that most patients will need long term retention regardless of whether teeth are extracted, and to a lesser degree to some of the advantages conferred by some of the newer appliance systems.

Nonetheless, there are many cases in which non-extraction treatment would be inappropriate, requiring excessive expansion with consequent damage to the teeth and their supporting structures. The OP should be reassured that premolar extractions as part of a carefully formulated and competently executed orthodontic treatment plan have been shown, beyond any reasonable doubt, to be entirely safe.

carrickmilo

I disagree and don't think removing 4 healthy teeth is worth the risk of developing TMJ dysfunction later in life.

The guy adjusting my post-surgical repositioning splint tells me his TMJ dysfunction patients are either those who have had 4 pre-molars removed, the majority, or people who have suffered whiplash in MVAs. Both can cause the discs to dislocate.

What I learned in my journey is that there are different schools of though when it comes to occlusion, orthodontics and TMJ problems. There are the old school guys with their dogma circling the wagons and more the progressive functional jaw orthodontics / orthopaedics group who instead of looking at the teeth in isolation condsider the position of the condyles. I saw some guys who in retrospect knew nothing about the actual problem I had and wanted to start me into treatment based on guesswork with no proper diagnostics carried out.

FruitLover

carrickmilo wrote: »

We were designed to have 32 teeth

Nope. Wisdom teeth are a built-in redundancy to counter the fact that before humans discovered dental hygiene, it was normal to lose 4+ teeth before adulthood (hence the frequency of impacted wisdom teeth in modern humans with a full complement of adult teeth).

kkth0360

carrickmilo wrote: »

I disagree and don't think removing 4 healthy teeth is worth the risk of developing TMJ dysfunction later in life.

The evidence on this is very clear - there is NO increased risk of developing TMJ dysfunction associated with premolar extractions. This is not just my viewpoint, or the viewpoint of these "old school guys" you mention: it is scientific fact backed up by an enormous amount of rigorous, peer-reviewed scientific evidence. Incidentally, there are many studies using MRI and cone-beam volumetric CT scanning to investigate changes in disc position during orthodontic treatment with and without extractions - no differences are found between the two groups.

Your TMD guy clearly believes there is a link, based presumably on anecdotal evidence from his own group of patients. He has chosen to ignore the vast body of published evidence in favour of his own, comparatively limited data. That's his choice. My choice is to critically appraise the published research on an ongoing basis and to base my clinical decisions accordingly

Incidentally, the "progressive" functional jaw orthodontics / orthopaedics group operate largely on the fringes of science and their literature abounds with theory, conjecture and opinion, but very little actual evidence (and absolutely no high level evidence of the RCT / systematic review variety).

At the end of the day, you believe that your TMJ problems are a result of your extractions, and this belief has been reinforced by your TMD guy's anecdotal claim that most of his patients are 4 premolar extraction patients. I believe otherwise. But don't take my word for it: read the paper I've linked to above, or search PubMed for peer reviewed research papers on the subject and draw your own conclusions.

flahavaj

carrickmilo wrote: »

I disagree and don't think removing 4 healthy teeth is worth the risk of developing TMJ dysfunction later in life.

You cannot "disagree" with an overwhelming body of evidence that categorically states that there is no link between orthodontic treatment/premolar extractions with temperomandibular disorders. Especially when you produce absolutely no evidence to the contrary.

Do you have any evidence or are you just making unsubstantiated claims?

carrickmilo

Sometimes it takes a while for the vanguard to become accepted. There are many examples in medicine when new findings have been rubbished by the establishment and when I read the vehement tone of some replies here I wonder why so defensive?

Flahavaj if you read my post carefully you would see that I provide evidence for my claim although another poster has tried to dismiss it as 'anecdotal'

Standard Toaster

Hi,

This thread has really took off!

kkth0360 wrote: »

Hi,
Premolar extractions for orthodontic treatment are usually fairly straightforward since the teeth are normally intact and easily accessible. You'll feel a bit of pushing and pressure, and hear some creaking or cracking noises (completely normal) and the tooth will be out in about 10 seconds or so.

Occasionally a little bit of the tip of the root will fracture off and be left behind - this is largely due to the root anatomy of these teeth, and very seldom causes any problem with the subsequent orthodontic work.

Often, a dentist will suggest doing the extractiions in 2 visits - upper and lower on one side first and then the other side a week or so later. This makes it more comfortable to eat after the extractions, and also avoids having your entire lower lip and tongue numb from the anaesthetic if both sides are done together.

Not sure about the cost - I'd guess around €200-€300 for 4 simple extractions, but perhaps one of the General Dentists will correct me on this?

Best of luck

Hi,

This was exactly how I found the whole experience! A tiny tip of the root on the top right did infact break away (less then a millimeter I would say) and the dentist said it shouldn't be anything to worry about. I had the 4 teeth out in 2 visits in the space of a week...like you said...upper and lower on one side first and then the other side a week or so later. For anyone who maybe getting the same done I found it all 'fairly' painless. There was a few hours of discomfort after the anaesthetic wore off after the second visit but nothing major. Cost was 90 euro a tooth at about 15/20mins a visit.

I've been looking up TMJ dysfunction this evening too btw :eek::)
I do have a slight movement in my jaw if I open it very wide, like a slight jaring movement to the left/right as I open/close my jaws. I have this for as long as I remember. No pain (yet anyway!) The dentist did notice it too and asked was it painful. Didn't seem too concerned when I said it wasn't. Advised that getting the teeth out and having the braces shouldn't make it any worse. Fingers/toes crossed they're right!

I was ment to have the fitting of the braces on Friday but it's been pushed forward until mid December now as the orthodontist will not be available. The letter from them only arrive today so I'm kinda pissed of at that.
Anyway, thanks for all the input on the thread guys

ballsymchugh

FruitLover wrote: »

Nope. Wisdom teeth are a built-in redundancy to counter the fact that before humans discovered dental hygiene, it was normal to lose 4+ teeth before adulthood (hence the frequency of impacted wisdom teeth in modern humans with a full complement of adult teeth).

noooo.. before man started cooking food and had to chew the bejaysis out of food before it was swallowed, the muscles and jaws developed differently allowing plenty of space for the wisdom teeth to come through. this can be seen on some masai tribes that have almost 15mm of space behind their wisdom teeth. impacted wisdom teeth is one of the few signs that we're still evolving. even when some people still can't stand up fully.

and tooth loss due to decay only really became an issue after the introduction of refined sugar into the diet. think the study in tristan da cunha supports that, twas drilled into us... pardon the pun.

ballsymchugh

90 snots?!! jaysis, i need to review pricing!!

Standard Toaster

Oh and just to add, just about everyone on my family has bad teeth...I blame the aul lad! Just luck of the draw....bad DNA and being Irish

Standard Toaster

ballsymchugh wrote: »

90 snots?!! jaysis, i need to review pricing!!

What do you charge a nasher?

ballsymchugh

The_Edge wrote: »

Oh and just to add, just about everyone on my family has bad teeth...I blame the aul lad! Just luck of the draw....bad DNA and being Irish

and sweets.

we charge 50.

Standard Toaster

No, no sweets. Just bad teeth.

€50 swabs, pity I've no more teeth that need removing!

Big_G

Back on topic. First of all, the highest level of evidence is a meta-analysis, not a systematic review. Secondly, a systematic review is only as good as the quality of the studies included in it. Unfortunately the link provided does not show a full text, so it is hard to judge the quality of the systematic review.

Second, the evidence that is provided by Carickmilo is anecdotal, which is the least high quality evidence available. Why haven't the people you have seen published in journals about their experiences or designed studies to back up their theories?

I think this is a really good discussion so far. I don't think, Carickmilo, that you need to be upset about orthodontists still recommending premolar extractions. As you can see, the consensus is that orthodontic treatment does not contribute to TMJ problems. And that would include premolar extractions, I presume.

If you want to talk about an anecdote with regard to this issue, mine is a good one. I had orthodontic treatment in the States at a young age, and at the time they were very much against extractions in orthodontic therapy. I completed my treatment in Ireland, where they recommended that I have my premolars x4 removed. I didn't do it. Fast forward to today where I have relapsed, and have had to have a lower incisor extracted due to late lower incisor crowding (I had 4 impacted wisdom teeth removed before the incisors started to crowd). I also have crepitus in the right tmj, which I suspect is due to a clenching habit, not any orthodontic treatment I may have had.

So my anecdote contradicts your anecdote. Which is an example of why anecdotal evidence is considered poor quality.

carrickmilo

Big_H a clenching habit can mean you have a problem with your bite.
Clenching or grinding is the brain's unconscious way of trying to get the jaw into the correct position. People say its stress but since my bite was corrected with a repo splint I'm not waking up multiple times during the night firmly locked down. For me there is a clear cause / effect chain here.

http://www.tjspahldds.com/images/twins.jpg

These are identical twins, the one on the left had 4 pre-molars extracted, her sister didn't. I would hazard a guess and say that she has healthier TMJs plus the fact she looks prettier, her face developed the way nature intended and doesn't have that kind of pinched look.

Big_G

carrickmilo wrote: »

Big_H a clenching habit can mean you have a problem with your bite.
Clenching or grinding is the brain's unconscious way of trying to get the jaw into the correct position. People say its stress but since my bite was corrected with a repo splint I'm not waking up multiple times during the night firmly locked down. For me there is a clear cause / effect chain here.

http://www.tjspahldds.com/images/twins.jpg

These are identical twins, the one on the left had 4 pre-molars extracted, her sister didn't. I would hazard a guess and say that she has healthier TMJs plus the fact she looks prettier, her face developed the way nature intended and doesn't have that kind of pinched look.

I have had my bite analysed and I have a very good MIP relationship, with no interferences or mip to cmmr slides. Nothing to indicate that my bite is causing a parafunctional habit. In fact the orthodontist wouldn't change my bite because it was right. Instead of premolar extractions and changing the bite, he recommended extraction of an incisor instead. For every case where you might think there is a cause and effect in occlusion/tmj I can show you one where there isn't.

As far as the twins, beauty is in the eye of the beholder.

flahavaj

carrickmilo wrote: »

Sometimes it takes a while for the vanguard to become accepted. There are many examples in medicine when new findings have been rubbished by the establishment and when I read the vehement tone of some replies here I wonder why so defensive?

Flahavaj if you read my post carefully you would see that I provide evidence for my claim although another poster has tried to dismiss it as 'anecdotal'

Thats because it is anecdotal. Post some links to some scientific studies. Stories about twins don't count. Temperomandibular Disorders have a multifactorial biopsychosocial aetiology. Posting pictures of twins and saying one looks better than the other after premolar extractions is totally irrelevant to this discussion. At the moment all you have is a theory, with no proof to back it up. Which is worthless.

Bottom line: start producing some hard factual evidence to back up your spurious claims.

carrickmilo

These are identical twins. One was told she had 'overcrowding' and had four pre-molars removed and orthodontics to close the gaps. The other got to keep all her teeth and had braces to widen her dental arches.

I don't know if TMJ dysfunction is an issue in both these cases. All I said was I would hazard a guess that the twin with the fully formed arches has healthier TMJs. I don't have any scientific studies to back up this claim, all I have is common sense. If our bodies were designed to be a certain way why play God? Removing healthy teeth is like a form of mutilation.

ballsymchugh

carrickmilo wrote: »

These are identical twins. One was told she had 'overcrowding' and had four pre-molars removed and orthodontics to close the gaps. The other got to keep all her teeth and had braces to widen her dental arches.

I don't know if TMJ dysfunction is an issue in both these cases. All I said was I would hazard a guess that the twin with the fully formed arches has healthier TMJs. I don't have any scientific studies to back up this claim, all I have is common sense. If our bodies were designed to be a certain way why play God? Removing healthy teeth is like a form of mutilation.

because people like straight teeth!! well, a lot of people do anyway.
the photos of the twins merely shows that the two were treated by different methods. you can't deduce by looking at the photos that one will have no problem with her tmjs. on a different point, the case of the twins is similar to the argument used to promote orthotropics, and having met the guy that developed the idea numerous times on one of his courses(and it wasn't a weekend one!), i can't remember the tmj being mentioned once.

kkth0360

Originally posted by Big_G
Back on topic. First of all, the highest level of evidence is a meta-analysis, not a systematic review.

Actually systematic reviews, either with or without meta-analysis, are considered level 1 evidence (the highest level).

Secondly, a systematic review is only as good as the quality of the studies included in it. Unfortunately the link provided does not show a full text, so it is hard to judge the quality of the systematic review.

Agreed (incidentally, this is also the case with meta-analyses). The full text link from PubMed seems to be malfunctioning - you can read the paper here.

As for the twins photos - this single case report has been used by Terrance Spahl since the 1980s, when he used it in a book chapter he co-wrote with John Witzig to back up their claims that orthodontic extractions gives rise to dished-in facial profiles, and in which they coined the phrase "the orthodontic look". Once again, no actual evidence was produced by either Witzig (now deceased) or Spahl at the time or since in support of this accusation, which Spahl continues to preach. On the other hand, there is a wealth of evidence that extractions as part of well planned and executed orthodontic treatment do not have any detrimental effects on the facial profile. One such study, by Rushing (1995), investigated the degree by which general dentists and specialist orthodontists were able to differentiate between patients treated with or without extractions by looking at their facial appearances. Their results revealed that "dentists' judgments of facial profiles are neither more nor less accurate than a coin toss"!

"Hazarding a guess" or using what you might perceive as "common sense" are not appropriate grounds on which to base an informed opinion or make a clinical decision, particularly when there is robust scientific evidence to the contrary.

vishal

my two cents:
extractions can be very beneficial in orthodontics and can often improve facial appearance in some malocclusions i.e. bimaxillary protrusions
and can provide acceptable CII and CIII camouflage that would otherwise require invasive surgery.

i don't believe orthodontics in general can cause tmj unless done poorly with very heavy forces and poor torque control. (this probably goes against the research)
i do believe in a few cases (cr desrepancies) orthodontics can prevent future tmj in susceptible patients and in few cases can be used to treat tmj (i don't think one should ever do orthodontics to treat tmj however, but rather to treat the malocclusion and if symptoms go away, it's a bonus)

flahavaj

carrickmilo wrote: »

I had a serious problem with my TMJ and had to have disc plication surgery in the US. When the surgeon went in he saw that the disc was 40% displaced anterior to the articular eminence. I am now wearing a repositioning splint and using a Therabite exerciser. This is all part of a tried and tested treatment protocol.

I am having the splint adjusted by a dentist colleague in Ireland. He tells me that the VAST majority of the TMJ dysfunction patients he sees are those like me who have had 4 pre-molars removed for earlier orthodontics (the remainder are mainly people who have suffered whiplash).

You can throw all the studies at me and I will still say this is a red flag and needs to be investigated

What I learned it that in medicine there is frequently a status quo situation where new approaches are seen as a threat and dismissed and I'm just thinking the way this thread is developing kind of confirms this suspicion. Why not be open minded and say hey this poster is speaking from experience, he may be a lay man but lets respect his view.

It has been investigated and at great lengths. And it has been found that there is no link between TMD d premolar extractions. I don't know what else to say to you in the absence of you providing any evidence to the contrary.

As for being open-minded, surely ignoring factual evidence is as narrow minded as you can possibly be?

carrickmilo

http://www.ncbi.nlm.nih.gov/pubmed/19783804?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=4

flahavaj

carrickmilo wrote: »

http://www.ncbi.nlm.nih.gov/pubmed/19783804?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=4

Huge difference between extracting first premolars for orthodontic reasons and then realigning the teeth to produce a stable occlusion with all permanent molars and the remaining premolar present and a lack of posterior support causing an unstable occlusion as per this study.

Proves nothing.

georgieporgy

do any of the specialists here (or GPs for that matter) use a T-Scan for occlusal analysis?