Orthodontics Before Dental Implants — Space Opening and Alignment First

Why adjacent teeth tip into extraction spaces

When a tooth is extracted and the space is left unfilled, the neighbouring teeth experience a change in the force environment. There is no longer a contact point holding them in position on one side, and over months to years the teeth adjacent to the gap tip towards it. Lower molars in particular have a strong tendency to tip mesially — tilting forward — into a lower premolar or molar extraction space. Upper teeth may over-erupt downward towards a lower gap. Even a few millimetres of tipping changes the angle of the root substantially. A molar that has tipped 10 to 15 degrees into a space may now have its root encroaching on where the implant body would need to be placed, even if there appears to be adequate space at the gum line.

How orthodontic uprighting restores the correct architecture

Orthodontic uprighting uses brackets, wires, and sometimes auxiliary springs to rotate a tipped tooth back to its correct vertical angulation. As the root is moved back, the bone remodels around it — bone is deposited on the side the root moved away from and resorbed where it moved towards. This process actively creates bone in the area where the implant will be placed. The result after uprighting is parallel root walls on both sides of the space, adequate mesiodistal width at both the crown and root level, and a bone architecture that reflects the tooth's corrected position. CBCT imaging taken after uprighting often shows significantly improved bone volume compared to before treatment. This bone is vital: an implant placed into a narrow, poorly formed bony space has a much higher failure rate.

Space opening versus space closure decisions

Not all missing tooth cases require an implant. For patients with mild to moderate crowding elsewhere in the arch, orthodontic space closure — moving the teeth together to close the gap — may produce an excellent functional and aesthetic result without any implant at all. This avoids the ongoing cost of implant maintenance, eliminates the surgical component, and often produces a more natural appearance because the existing teeth fill the space. The decision between space opening for an implant and space closure depends on: the nature of the occlusion, whether there is existing crowding that benefits from space redistribution, the patient's aesthetic preferences regarding tooth size, and the quality of the teeth adjacent to the gap. An orthodontist and a restorative dentist or implantologist should jointly assess this decision — ideally at a combined consultation.

How long space can be maintained orthodontically

If a tooth has been extracted and the space has partially closed, orthodontic treatment can re-open it to the correct width. Once the space is open, a temporary tooth — either on the orthodontic retainer, a Maryland bridge, or a temporary partial denture — holds the space while the patient completes treatment and awaits the implant. Most orthodontists maintain the space until the implant crown is fitted and the case is complete. The total time from starting orthodontics to receiving the final implant crown is typically 18 to 30 months depending on the complexity of the alignment work and the healing time required after implant placement. Once the space is fully opened, most clinicians wait around three to six months before implant placement so the bone and periodontal ligament stabilise and the teeth do not drift back into the site.

Minimum space and root parallelism for an implant

A standard implant needs roughly 7 mm of mesiodistal space for an incisor and 7 to 8 mm for a premolar, with wider implants needing 8 mm or more. That measurement matters at root level, not just at the gum line, so it is confirmed on a periapical radiograph or CBCT. The roots either side should be parallel or diverge slightly towards the base of the space, giving the implant room to osseointegrate without root contact. Where lateral incisors are small or peg-shaped, a Bolton discrepancy between upper and lower tooth sizes can mean the planned space differs from the width of the missing tooth, with the crown or composite build-ups compensating. Most implant surgeons will not proceed until parallelism is confirmed.

Root angulation and its importance for implant viability

An implant is a titanium fixture placed into bone, and it must be inserted along an axis that avoids the roots of adjacent teeth. If those roots are tilted towards the implant site, the implant surgeon has less room to work and may be unable to achieve the correct angulation without risking root damage. Dental panoramic radiographs (OPGs) and cone beam CT scans (CBCTs) are used to assess this before implant placement. When orthodontic uprighting has been completed, a post-treatment CBCT will show the roots in their corrected positions and the surgeon can plan implant placement with confidence. Placing an implant without first uprighting tipped adjacent teeth is a well-documented cause of premature implant failure and root damage to neighbouring teeth.

The treatment planning sequence

The recommended sequence for a missing tooth managed with orthodontics and an implant is: initial assessment by both the orthodontist and the implant surgeon, orthodontic treatment to upright adjacent teeth, re-open space if closed, and correct any other alignment issues, post-orthodontic CBCT to confirm bone architecture and root positions, implant placement by the oral surgeon with the orthodontist's appliances removed or modified to allow access, healing period of three to six months for osseointegration, implant crown fitting by the restorative dentist, and finally orthodontic debond and retainer fitting. This sequence requires good communication between multiple practitioners and should ideally be coordinated from the outset rather than managed reactively.

Hypodontia: congenitally missing teeth and NHS care

Hypodontia, the congenital absence of one or more permanent teeth, is one of the commonest reasons for orthodontic space opening before implants, typically for missing upper lateral incisors or premolars. Under-18s whose IOTN score meets the threshold can receive NHS orthodontic treatment free of charge, which may include opening or maintaining the space. NHS hospital and dental school departments run multidisciplinary hypodontia clinics that coordinate orthodontics, restorative dentistry and oral surgery. Implants are usually placed once jaw growth has finished, so a teenager may hold the space with a retainer tooth or bonded bridge for several years.

When pre-implant orthodontics is not needed

Not every implant case requires orthodontic preparation. If the tooth was extracted recently and the space has not closed, if the adjacent teeth are well-positioned with parallel roots, and if CBCT imaging confirms adequate bone architecture, an implant can often be placed without prior orthodontic treatment. Cases where a single tooth was extracted in adulthood with good adjacent tooth positions may proceed directly to implant placement after appropriate healing time. The decision should be based on imaging rather than assumption — apparent space at gum level does not guarantee adequate root separation or bone architecture at implant depth.

NHS implants versus private costs in the UK

Dental implants are not available on the NHS except in very limited clinical circumstances, such as following jaw reconstruction after cancer surgery or in cases of severe congenital defects. For the vast majority of patients in the UK, implants are a private treatment. A single implant including crown typically costs between £2,000 and £3,500. Where orthodontic treatment is also required, this typically adds £1,500 to £5,500 depending on the appliance and complexity, so a combined plan for one implant commonly totals £4,000 to £9,000 or more. Patients should request a combined treatment plan with costs outlined at the outset so that the full commitment is understood before treatment begins. Some practices offer staged payment plans across the duration of treatment.

When orthodontics alone avoids the implant entirely

Space closure is a particularly attractive option for lower first premolar and lower second premolar extractions, where moving the canine backward or the molars forward can produce a perfectly functional occlusion without any implant. It is also used routinely in children and teenagers who have teeth extracted as part of planned orthodontic treatment — in these cases no implant is ever needed. Adults should not assume an implant is the only option for a missing tooth. Discussing space closure with a specialist orthodontist before committing to implant treatment can sometimes reveal a simpler, lower-cost, and equally good long-term solution.

Useful related pages

This guide is for general information only. It is not a diagnosis, treatment plan, or substitute for advice from a registered dentist or orthodontist.