The question of whether to remove wisdom teeth before starting orthodontic treatment is a frequent concern for patients preparing for braces. Wisdom teeth, or third molars, are the last teeth to erupt, typically appearing between the ages of 17 and 25. Their emergence often coincides with a period when the jaw has finished developing, leading to potential space conflicts. The decision to remove them is highly individualized, depending on the position of the teeth and the specific goals of the orthodontic treatment plan.
The Orthodontic Rationale for Wisdom Tooth Removal
Orthodontists are primarily concerned with how the presence of developing or impacted third molars might affect the long-term stability of a newly straightened smile. Historically, the belief was that these late-erupting teeth caused front teeth to crowd or relapse after braces were removed. Contemporary research suggests that wisdom teeth do not possess enough force to push the anterior teeth out of alignment; late-stage crowding is now attributed to natural aging changes and a lack of proper retainer wear.
Despite the shift in understanding regarding anterior crowding, third molars remain a concern for space management in the back of the mouth. If the treatment plan requires the movement of posterior teeth, removal provides the necessary space for alignment. Furthermore, if the wisdom teeth are partially or fully impacted, they pose a direct threat to the adjacent second molars. Removing them prevents potential damage, such as root resorption or decay, to these healthy teeth.
This preemptive removal also eliminates the risk of future complications that could interrupt the active phase of orthodontic treatment. An acute infection or painful eruption while wearing braces would require immediate attention and potentially delay the overall treatment timeline. Addressing the third molars early allows the orthodontist to proceed with the alignment process on a stable foundation.
Key Diagnostic Factors Guiding the Removal Decision
The decision to remove wisdom teeth is based on a detailed assessment of their developmental status and surrounding anatomy, not age alone. Diagnosis starts with panoramic X-rays, providing a two-dimensional view of the jaw and unerupted teeth. In complex cases, a Cone-Beam Computed Tomography (CBCT) scan provides a three-dimensional image, which is used to assess the proximity of the roots to nerve canals.
A primary factor is the degree of impaction, classified by how much of the tooth is covered by bone or gum tissue. A tooth is fully impacted if encased in the jawbone, while it is partially impacted if it has broken through the gum line. Partially erupted teeth are often removed because they create an opening for bacteria that is difficult to clean, leading to infection.
The angle of growth is another factor guiding the removal recommendation. Wisdom teeth growing at an abnormal angle are unlikely to erupt into a functional position. They may be angled toward the second molar (mesial impaction), away from it (distal impaction), or lying completely sideways (horizontal impaction). Any angle that threatens the integrity of the adjacent tooth or the jawbone usually warrants extraction.
The stage of root development also plays a role in timing the procedure. Extraction is less complicated and recovery is faster when the roots are approximately two-thirds formed, usually in the late teens. This timing prevents the roots from becoming fully mature and deeply anchored in the denser jawbone of an older adult. The final decision is collaborative, made by the orthodontist and an oral surgeon after reviewing imaging and clinical findings.
Optimal Timing: Before, During, or After Braces?
Most dental professionals recommend removing problematic wisdom teeth before beginning orthodontic treatment. This timing allows the patient to fully recover from the surgical procedure before the braces are placed. The typical healing period is about two to four weeks, after which the mouth is stable enough to begin tooth movement. Starting with a cleared dental arch ensures a smoother and uninterrupted orthodontic process.
Removing the teeth during the active phase of treatment is generally avoided unless an acute issue arises, such as a painful infection or sudden cyst formation. Brackets and wires complicate surgical access for the oral surgeon. Furthermore, post-operative healing time temporarily halts planned tooth movement, potentially extending the overall time the patient spends in braces.
Extraction after the completion of treatment is an option only if the third molars are fully erupted, healthy, and positioned correctly. If the wisdom teeth are not causing immediate issues, the orthodontist may monitor them with periodic X-rays. If they are impacted or show signs of future trouble, removal after braces protects the final result and prevents later dental complications.
Potential Risks of Retaining Wisdom Teeth
Retaining impacted or partially erupted wisdom teeth carries several risks to long-term oral health. One common issue is pericoronitis, a painful infection and inflammation of the gum tissue surrounding a partially exposed tooth. This occurs because the gum flap creates a pocket where food debris and bacteria become trapped and are impossible to clean effectively.
Impacted teeth can damage the adjacent second molar through chronic pressure or by creating a site for decay. Pressure can lead to root resorption, which is the breakdown of the second molar’s root structure. The difficult-to-clean space between the molars often results in decay affecting both the third and second molar simultaneously.
In severe cases, a fluid-filled sac called a dentigerous cyst can form around the crown of an unerupted third molar. As this cyst grows, it can cause destruction of the surrounding jawbone and damage to the roots of nearby teeth. Though rare, these cysts sometimes develop into benign tumors, necessitating a complex surgical procedure to remove the growth and repair the damaged bone structure.