Serial extractions

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Serial extractions

 Interceptive orthodontics: “that phase of science and
art of orthodontics employed to recognize and
eliminate potential irregularities and malpositions in the
developing dentofacial complex”
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SERIAL EXTRACTIONS
 As we learn more about growth & its potentials, influences of
function…………, normal mesiodistal position to basal jaw
bones and head structures, we will acquire a better understanding
of when and how to intervene in the guidance of growth
processes so that Nature may better approximate her growth
plan for the individual patient………………..
-----CHARLES H. TWEED

Serial Extractions: Definitions-
 DEWEL,1969- “ selected deciduous and permanent teeth in a
predetermined sequence”
 “Correctly timed, planned removal of certain deciduous and
permanent teeth in mixed dentition cases with dento-alveolar
disproportion in order to
Alleviate crowding
Guide unerupted teeth
Lessen/eliminate period of active appliance therapy
“Sequential plan of premature removal of one/more deciduous
teeth in order to improve alignment of succedaneous permanent
teeth and finally removal of permanent teeth to maintain the
proper ratio between tooth size and available bone”

Serial Extractions: Historical development
 Palsson(1956)
 Robert Bunon (1743) “ESSAY ON DISEASES OF THE
TEETH”- first reference
 Joseph Fox (1814)- ext of deciduous canine absolutely necessary
 Linderer(1851)- stripping of canines, premolar extraction.
 Nance (1940)- “Father of serial extraction”
 Rudolf Hotz (1948)-article- early planned extractions.
 Birger Kjellgren (1947) 1st post war congress of EOS-
SERIAL EXTRACTIONS
 Hotz-active supervision of eruption---*guidance of eruption*

Serial extractions: Historical development
 B .F. Dewel (1967) “ growth prediction”
 Future growth is inadequate.
 Charles H. Tweed (1969) 8yrs of age.
 Rudolf P. Hotz (1970)
 T. M. Graber (1971) eg of multidiscipline approach that
exemplifies the best to be gained from team work.
 Jack G. Dale (1976)

Serial extractions: Rationale
 Early mixed dentition.
 Arch length-tooth material discrepancy
 Physiologic tooth movement
 Harmonize the tooth material to archlength
 Correct the dental irregularities-maintaining the multisystem
balance and the best possible facial harmony

Chief Benefits of Extraction Guidance:
 Naturally induced movement and alignment
 Improved health of investing tissues
 Improved psychologic state & patient compliance
 Reduced total workload and treatment effort
 Less potential iatrogenic damage.
 Better oral hygiene
 More stable results

Possible clinical clues for serial extraction
Indications:
 Class I malocclusion
 Arch length deficiency
 Absence of physiologic spacing
 Premature loss of primary canine
 Crowded upper and lower anteriors
 Mal positioned lateral
 Localized gingival recession
 Ectopic eruption of teeth
 Mesial migration of buccal segment
 Abnormal eruption pattern & sequence
 Ankylosis
 Growth not enough

Clues for serial extraction :(Dale)
hereditary crowding

Clinical Clues:

Environmental crowding:
•Important to differentiate

Environmental crowding:

Limitations:
1) Deepening of bite (Dewel 1967)
2) Premolars fail to reach their normal occlusal level.
3) Facial esthetics
4) Nose and chin growth (exceeds)
 important to differentiate b/w authentic serial
extraction, & deceptive borderline irregularity

Contraindications
 Congenital absence of teeth
 Mild-moderate crowding
 Deep bite
 Severe class II, III of dental/skeletal origin
 Cleft lip and palate
 Spaced dentition

Disadvantages:
 Requires clinical judgement
 Prolonged treatment time
 Patient compliance
 Developing tongue thrust
 Arch length reduction
 Ditching b/w canine and second premolar
 Axial inclination

Precautions:
 Based on proper diagnosis
 3-5 yr old period of observation

Dependence on maxillo-mandibular
relationship
• Normal, good interdigitation Good chance
•If abnormal- with caution
Dewel “severe class II discrepancy irregularities treated
primarily with class II mechanics, with serial extraction more or
less an accessory to mechanotherapy”
Mayne(1959)…present harmony and balance of two
tissue systems, bone and muscle, & varying degree of
disharmony in third…. Apical bases located directly one
under the other……….produce complimentary facial
esthetics

Dental development
Dental age
(Hurme)

Dental development
 Incisal liability and the associated changes in the
dental arches:
 Increase in anterior tooth mass
 G. V. Black (1902)- 7.6mm and 6mm larger
respectively
 Warren Mayne (1969)
 See child at 7yrs of age- AAO

Incisal liabilities

Factors that allow for or prevent proper
alignment of erupting permanent teeth
 Inter dental spacing of primary teeth
 Inter canine arch width change
 Increase in arch length
 Favorable variation in the ratios b/w size of pri and
permanent teeth

Interdental spacing
 0-10mm avg 5mm in
maxillary arch
0-6mm avg 3mm in
mandibular arch
 First observation

Early manifestation
To overcome:
•Greater than avg growth response
•Extremely small permanent teeth

Intercanine Arch Width Changes:
 Increase at the time of eruption of permanent
incisors
 Moorrees et al (1965): sexual dimorphism
 Boys: b/w 2yr -18yr :- 6mm
 Girls: b/w 2yr-12yrs :-4.5mm
 Growth of arches??
Graber and Enlow- appositional growth----------
during transition to result in a larger arc

Intercanine Arch Width Changes:

Arch length change:
John Hunter in 1771 “the jaw still increases in all points till
12months after birth, when the bodies of all 6 teeth are pretty
well formed; but it never after increases in length b/w the
symphysis and the sixth tooth…...After this time the jaws
lengthen only at their posterior ends.

Reduction in arch length
Moorrees (1965)

•Labial positioning of erupting incisors:
-influence arch length
Baume: (1950) 2.2mm---maxi anterior positioning
1.3mm---mand anterior positioning

Variations in the size ratio of primary teeth
and their permanent successors

Leeway space of Nance:
Reserved space

Early & Late Mesial Shift:

Diagnosis
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Assessments to be made before a serial
extraction procedure is contemplated:
 Total dentofacial morphology & the physiologic
ramifications of growth and development
 Diagnostic process involves:
 Case history
 Clinical examination
 Photographs
 Study models
 Cephalometric, panoramic,
periapical radiographs
Dynamic working analysis

Proportional facial analysis
Graber (1971)
Standard or orthognathic face

Alveodental protrusion:
Class I maxillary mandibular
protrusion

Alveodental protrusion:
Class II maxillary alveodental protrusion
Only in the maxilla

Alveodental retrusion
Class I maxillary mandibular alveolodental
retrusion
Not indicated

Alveodental retrusion:
Class II mandibular alveodental retrusion

Prognathism:
Class I maxillary mandibular prognathism

Prognathism:
Class II maxillary prognathism

Retrognathism:
Class I maxillary-mandibular retrognathism

Retrognathism:
Class II mandibular retrognathism

Space analysis in mixed dentition
 Assess the tooth size-arch
length relationship
 Prediction of tooth size of
unerupted teeth

Dental Analysis:
 Incisors:
 Favorable situation
 Precarious situation
 Impossible situation

Molars
1. Upper 1st molar emerge before lower
2. Interproximal caries
3. Premature loss of primary molars
4. Ectopic eruption
Canines, premolars and 2nd molars
• Favourable sequence of eruption
• Upper 2nd molar erupt before- class II molar relation
• Early exfoliation or prolonged retention of pri 2nd molar
Soft tissue profile

SERIAL EXTRACTIONS:

Sequence of extractions:
 No single extraction sequence
 In 1743, Bunon—C-------D------4
 Berger, Kjellgren, Rudolf Hotz, John Heath,
L.J.Baume, Hayes Nance & Dewel-------over 50yrs
D---4----C
 Only in lower arch

Guide to selecting suitable extraction
sequence:
1. Extracting primary canines only
2. Extracting the primary first molars only
3. Extracting both primary canines and first molars
4. Enucleation of first premolar buds (danger of
knife edging) rarely indicated in maxillary arch

Serial extraction procedure:

Serial extraction in Class I treatment
Group A: Anterior Discrepancy (crowding)
Step 1

Class I Anterior Discrepancy (crowding)
Step 2

Step 3

multi bonded treatment
Step 4

Retention
Step 5
Aligned in harmony with the craniofacial skeleton &
soft tissue matrix

Post-Retention (18yrs)

Group B: Class I Alveodental Protrusion
Step 1

Class I Alveodental Protrusion
Step 2

Step 3

Step 4

Group C: middle discrepancy-impacted
canines
Discrepancy -- severe
4’s erupting ahead of canines

Group C: middle discrepancy-impacted
canines

Group D: Enucleation in the mandible
Maxilla- premolars erupt before canine

Group E: Enucleation in the maxilla &
mandible
No opportunity exists to place multibanded appliances

Group F: alternative to enucleation
Least desirable extraction result

Serial extraction in Class II
 Initial Period of interceptive treatment
1. extract upper D&4 , fixed appliance on E,6,1&2
2. extract lower C.
extract D and 4
fixed appliance on lower E,6,1&2
 Extraction for Rx of Class II malocclusion
 Proportional facial type, total space analysis.
 Period of interceptive guidance
 Retention appliance, regular recall.
 Second period of active treatment

In contemporary orthodontics:
 Trend ---nonextraction
 Fuller profile.
 Serial extraction with slight modification

Though serial extraction is a effective method for
treating class I crowding with either no or min
appliance therapy. But in contemporary
orthodontics where there is a trend towards non
extraction treatment and a fuller profile, the serial
extraction procedure can be used with a slight
modification ie extracting C & D as usual and
avoid extraction of 4 if possible and use other
means of gaining space like expansion,
proclination, interproximal red, molar distzn
either done alone or in combination as dictated
by the individual case

References:
 Orthodontics- Current Principles and Techniques:
Graber & Vanarsdall
 Orthodontic Principles & Practice- T.M. Graber
 “Serial extraction: A continuous diagnostic and decisional
process”- AJO 1971 Dec, vol 60, no.6 -T.M. Graber
 “Serial extraction in orthdontics; indications, objectives &
treatment procedures”- AJO 1954 Dec-B.F. Dewel
 “Serial extraction: its limitation and contraindication in
orthodontic treatment” AJO 1967;53(12) 904-921- Dewel
 “Prerequisites in serial extraction” AJO 1969;87-93- Dewel

References:
 “Guidance of eruption versus serial extraction”
AJO,1970;58(1) 1-20- Hotz P.R
 JCO interviews with Jack Dale on serial extractions-
Part 1,2,3: 1976
 “A consideration of dental development in serial
extraction” Angle Orthod 1963; 33: 44-59- Moorrees et al
 “Contemporary Orthodontics” –Proffit W.R
 “Dentistry for child and adolescent” –Mc Donald
 “A Textbook of Orthodontics”- Samir. E. Bishara

Serial extractions

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