Serial extraction.pptx

Serial Extraction
Presented by Dr. Farayola

Outline
• Introduction
• Definitions
• Historical development
• Rationale
• Indications
• Contraindications
• Advantages
• Disadvantages
• Criteria
• Diagnostic procedures
• Techniques
• Conclusion
• References
9/27/2022 Serial Extraction 2

Introduction
Serial extraction/guidance of eruption is the planned extraction of certain deciduous teeth and specific permanent
teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into a more favorable
position.
It is done to encourage the early eruption of the first premolars ahead of the permanent canines and should only be
considered where there is an arch discrepancy of >4 mm.
And it is usually limited to the upper arch as serial extractions in the lower arch usually results in lingual collapse of the
lower anterior segment.

Definition
• Serial extraction is an interceptive orthodontic procedure undertaken in the
(early) mixed dentition period that involves planned removal of certain primary
and permanent teeth in a programmed sequence, so as to relieve crowding in
the arches and to guide the remaining erupting permanent teeth into a more
favorable position.

…more definitions
• Proffit – Timed extraction of primary and, ultimately, permanent teeth
to relieve severe crowding
• Dewel -An orthodontic treatment procedure that involves the orderly
removal of selected deciduous and permanent teeth in a
• Bernard Lloyd-Early recognition or anticipation of a deformity that will
occur unless teeth are removed at strategic intervals to relieve intensity
• Tandon S- Defined as correctly timed, planned removal of certain
deciduous and permanent teeth in mixed dentition cases with dento-

Historical development
• Serial extraction is not new. It has been of interest to dentists for many years. Throughout the history
of dentistry, it has been recognized that the removal of one or more irregular teeth would improve the
appearance of the reminder.
• Paisson was the first to recommend the procedure to relieve the crowding and align the
relieve the crowding and align the teeth.
• Robert Bunon in 1743, in his publication“Essay on Diseases of Teeth”, first wrote about the
Teeth”, first wrote about the importance of early extractions.
• Linderer in 1851 suggested that the primary canines should be stripped or removed to
stripped or removed to accommodate the lateral incisors followed by the extraction of 1st
premolar so as to provide sufficient space for the eruption of molars.

Historical development (2)
• The following names stand out particularly for the modern development of the serial
extraction concept, Kjellgren of Sweden, Hotz of Switzerland, Heath of Australia and Nance,
Hoyd, Dowel and Mayne of the United States.
• The term “serial extraction” was used for the first time in 1929 by Kjellgren of Sweden.
• Hayes Nance is known as the Father of serial extraction in the United States and in 1940s
the United States and in 1940s he popularised the technique in the United States as
“planned and progressive extraction”.

• In 1941, Rudolf Hotz suggested the term “Guidance of dental eruption by
extraction” or “Guidance of eruption”. According to him, the term is self-
explanatory and comprises of all measures available for influencing tooth eruption.
• Widespread adoption of serial extraction as a corrective treatment procedure
continues to be a source of concern to all Pedodontists who are aware of its
limitations as well as of its possibilities, since it application involves growth prediction.
Historical development (3)

Rationale
Serial extraction is based on 2 basic principles:-
1. Arch Length tooth material discrepancy
2. Physiologic tooth movement

Arch Length tooth material
discrepancy
Whenever there is an excess of
compared to the arch length a
of some teeth is done so that rest
be guided to normal occlusion.
Courtesy: CDH, Luth dental clinic

Physiologic tooth movement
• Human dentition shows a
move towards an extraction
• Thus, by selective removal of
of the teeth which are in the
are guided by the natural forces
spaces
Courtesy: CDH, Luth dental
clinic

Indications
In class 1 malocclusion with no skeletal disproportions and showing harmony between skeletal
and muscular system with normal overbite & good skeletal profile.
Severe crowding with arch deficiency of 8-10 mm or more
Arch length deficiency as compared to the tooth material is the most imp. indication for serial
extraction.
* More details in next page

Arch
Length
deficiency
is
indicated
by the
presence
of one or
more of
the
following
features:
Absence of physiologic spacing
Unilateral or bilateral premature loss of deciduous canines with midline shift.
Malpositioned or impacted lateral incisors
Lingual eruption of lateral incisors
Irregular or crowded upper & lower incisors.
Localized gingival recession in the lower anterior region
Ectopic eruption of teeth.
Mesial migration of buccal segment.
Abnormal eruption pattern & sequence.
Lower anterior flaring.
Ankylosis of 1 or more teeth .

Courtesy: European Journal of Molecular & Clinical
Medicine
Absence of physiologic
spacing

Unilateral deciduous canine loss and shift to
the same side
Courtesy: European Journal of
Molecular & Clinical Medicine

Lingual eruption of permanent lateral incisor

Courtesy: European Journal of Molecular & Clinical
Medicine
Labial stripping, or gingival recession usually of lower incisor

Contraindications
Contraindications for serial extraction include
1. Congenital absence of teeth providing space
2. Mild to moderate crowding
3. Deep or open bites
4. Severe Class II, III of dental/Skeletal origin
5. Cleft lip and palate
6. Spaced dentition
7. Anodontia / oligodontia
8. Midline diastema
9. Dilacerations

Advantages
• More physiologic treatment as teeth are guided into normal positions using physiologic eruptive forces.
• Serial extraction allows the teeth to erupt over the alveolus and through –keratinized tissue, rather than
being displaced buccally or lingually.
• Reduce the duration & cost of active orthodontic treatment at later stage.
• Health of investing tissues is preserved with less potential for iatrogenic orthodontic damage like root
resorption, enamel decalcification.

Advantages (2)
• Psychological trauma associated with malocclusion can be avoided by treatment of the malocclusion at an
early age
• More stable result
• Less retention period is required.
• Better oral hygiene

Disadvantages
• Long-term procedure that requires thorough knowledge of growth, development, eruption sequence and
calcification of permanent teeth.
• No single approach can be universally applied.
• It is done as inter-canine growth is occurring and hence it is difficult to assess accurately how crowded
the dentition will be.
• Prolonged treatment time with multiple visits (2-3 year).

Disadvantages (2)
• Subjecting the child to early multiple progressive extraction visits can lead to patient and parent burn out
• High degree of patience and cooperation is needed from the patients.
• Most cases treated by serial extraction need to be followed by active orthodontic treatment (fixed
appliance) to achieve ideal leveling& alignment, root parallelism, closure of residual spaces, correction of
deep bite

Criteria for serial extraction
• Mild to moderate crowding due to lack of space for the permanent lateral incisors to erupt/crowded
anteriors
• The Occlusion must be Angle’s Class 1
• The skeletal pattern should be skeletal 1
• All teeth must be present on OPG and be in good position to erupt.
• The first premolars should be developmentally ahead of the canines.
• Absence of severe rotation of the anterior teeth

Diagnostic
procedures
• Extraction of any tooth is a critical step in orthodontic management. Thus, the
decision of resorting to serial extraction should always be based on comprehensive
assessment of dental, skeletal and soft tissues.
• Serial extraction is not a single-decision but a multi-decisional, time-lined process
where factors such as the amount of crowding, arch length requirements, whether to
extract the next set of teeth or not, and when to extract are re-evaluated at each
visit by the patient. Thus, serial extraction is a continuum of decision-making process
rather than a single-time diagnosis.
• The following investigations are recommended after a thorough clinical examination:
Orthodontic study model, Radiographs, Clinical photographs

Orthodontic study models
• Moderate to severe arch length-tooth material discrepancy of not less than 5–7
mm should exist to undertake the serial extraction procedure.
• Study models are required for:
1. Assessing the morphology of teeth
2. Assessing the dental arch form
3. Evaluation of occlusion
4. To perform model analyses - Carey’s analysis in the lower arch and Arch
perimeter analysis in the upper arch.
5. For patient education.

Orthodontic study
models
Courtesy: Orthodontic laboratory, Luth dental clinic

Various radiographic
views recommended
are:
Intraoral periapical view
Lateral cephalogram - To
analyse the skeletal relation
and direction of growth
using cephalometric analysis.
Orthopantomograph (OPG )
To detect congenitally
missing teeth and
supernumerary teeth
To carry out radiographic
mixed dentition analysis
To assess dental age
To assess the amount of
root development and
possible eruption pattern
To detect any bony
pathologies
Radiographs

Orthopantomogram

Lateral Cephalogram
Serial Extraction 9/27/2022 29

Clinical Photographs
• Pre, mid and post-treatment photographs are taken for extra and intra-oral views .They act as permanent records of pre-
treatment state, improvements during the procedure and also help in patient motivation.
• Extra-oral views:
• Face-Frontal (lips relaxed).
• Face-Frontal (Smiling).
• Profile (Right side preferably – Lips relaxed)
• (45 °) Profile (also known as ¾ Profile – Smiling).

Intra-oral views
There are five essential intra-oral photographs:
• Frontal – in occlusion
• Right Buccal – in occlusion
• Left Buccal – in occlusion
• Upper Occlusal
• Lower Occlusal

Techniques
A number of extraction sequences are in use and the choice of a particular method depends on individual case. No
single extracton sequence applies to all patient.
Some of the commonly used methods are described here.
• Dewel’s method
• Nance method
• Tweed’s’ method
• Grewe’s method.
• Moyers Method

Dewel’s Method (1978) (Extraction of CD4)
• Dewel proposed a three-step serial extraction procedure in 1978. This is the
most satisfactory order in most patients even today
• Step 1: Extraction of deciduous canines
• In this step, the deciduous canines are extracted at around 8-9 years to create
space for the alignment of the incisors.
• The main objective of extracting primary canines is to establish the integrity of
upper and lower incisors. This prevents the development of lingual crossbite of
maxillary laterals and resultant mesial migration of maxillary canines.

Dewel’s Method (1978) (Extraction of CD4) (2)
Step 2: Extraction of deciduous first molars
• In this step, deciduous first molars are extracted when first
evidenced by radiographs.
• This would be some 12 months after the extraction of deciduous
• The objective of deciduous first molar extraction is to accelerate the
ensures that the first premolars emerge into oral cavity, before the

Step 3: Extraction of first premolars
• In this step, first premolars are extracted as they are emerging into
canines have developed beyond half of the root length.
• Extraction of first premolars facilitates proper eruption and alignment
extraction procedure, the teeth are fairly aligned.
• However, the establishment of proper intercuspation usually requires
duration, although it may not be necessary in some cases.
Dewel’s Method (1978) (Extraction of CD4) (3)

Courtesy: International Journal
of Applied Dental Sciences

Nance method (D 4 C)
• Nance method of serial extraction is the modification of
Tweed’s method, which involves the extraction of the deciduous
first molars, followed by the extraction of the first premolars
and the deciduous canines.
Grewe’s method
• Grewe’s method of serial extraction is based on the planning
of extraction sequence for different clinical conditions.

Courtesy: International Journal of
Applied Dental Sciences

Stage I:
(Extraction of all
deciduous lateral
incisors). It helps in
alignment of central
incisors .
Stage II:
(Extraction of all
deciduous canines
after 7-8 months). It
helps in alignment of
lateral incisors and
provides space for
lateral incisors.
Stage III:
(Extraction of all
deciduous first
molars). It stimulates
eruption of all first
premolars.
Stage IV:
(Extraction of all first
premolars after 7-8
months). It provides
space for canines
and stimulates
eruption of canines
Moyers method
Indications
• When crowding is seen in central incisor region.
• Fairly eruption of lateral incisors.

Orthodontic Appliance following
Serial Extraction Procedure
• The most frequently used appliances with serial extractions
are;
• Maxillary and mandibular lingual arch
• Removable Hawley’s appliance
• Fixed appliance

Nance Appliance

Mandibular lingual arch

Courtesy:CDH, Luth dental clinic

Removal Hawley’s appliance

Conclusion
•Serial extraction is a planned procedure that demands a
minimum of 5 years’ supervision by the dentist of the
developing occlusion. Without such a commitment, the
objectives will not be fully achieved and at times, the child
is then left with a more severe malocclusion.

References
• Abu-Hussein Muhamad and Nezar Watted, Serial extraction in orthodontics. International Journal of Applied Dental Sciences
2019; 5(3): 370-378
• John Fricker and Julia Dando, in Handbook of Pediatric Dentistry (Fourth Edition), 2013.
• Dr. Appasaheb Naragond and Dr. Smitha Kenganal, Serial extraction. IOSR Journal of Dental and Medical Sciences
(JDMS)Volume 3, Issue 2 (Nov.- Dec. 2012), PP 40-47
• Dr. Arif Yezdani.A et al. Serial extraction in orthodontics. European Journal of Molecular & Clinical Medicine ISSN 2515-8260
Volume 07, Issue 2, 2020
• Sulagna Pradhan et al. Serial extraction:A review. Indian Journal of Forensic Medicine & Toxicology, October-December 2020,
Vol. 14, No. 4

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