Serial extraction



Introduction



Definitions



Historical development



Rationale



Indications



Contraindications



Advantages



Disadvantages



Diagnostic procedures



Techniques



Conclusion



References
2

 Dewel



1969

Serial extraction can be defined as
“the correctly timed, planned removal of certain
deciduous and permanent teeth in mixed
dentition cases with dento-alveolar disproportion
in order to:
3



Alleviate crowding of incisor teeth.



Allow unerupted teeth to guide themselves into
improved positions (canines in particular).



Lessen (or eliminate) the period of active
appliance therapy.

4



“It is a sequential plan of premature removal of

one or 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”.
5



an interceptive orthodontic procedure to intercept

and reduce dental crowding


carried out during mixed dentition period



Involves planned and sequential removal of
primary and permanent teeth

6

 Proffit

- Timed extraction of primary and,

ultimately, permanent teeth to relieve

severe crowding.

7

 “An

orthodontic treatment procedure that

involves the orderly removal of selected
deciduous and permanent teeth in a
predetermined sequence”

8

 Early

recognition or anticipation of a deformity

that will occur unless teeth are removed at
strategic intervals to relieve in intensity the
developing malocclusion.

9

 Defined

as correctly timed, planned removal

of certain deciduous and permanent teeth in

mixed dentition cases with dento- alveolar
disproportion .

10



Balance enforced extractions
Extraction of a tooth from the

opposite

side of the same arch, designed to minimize
centre line shift.


Compensate enforced extractions
Extraction of a tooth from the

quadrant

opposing

to the enforced extraction
11

 Arch

perimeter ( circumference)

-The distance from the mesial contact of one
first permanent molar to its antimere as measured
through the contact points or buccal cusp tips of all
of the intervening teeth.

12



Arch length( depth)

- the perpendicular distance from

a point between the central
incisors to a line connecting the
mesial contacts of the first
permanent molars

13

Arch width:


Inter- canine width: perpendicular distance cusp tip
of one canine to that of opposite canine.



Inter-molar width: perpendicular distance from
mesial pit of one molar to that of opposite molar.

14

 Paisson

was the first person
who pointed the extraction
procedure in order to improve
the irregular alignment and
crowding of teeth.

16



The names that stand out particularly for the modern
development of the serial extraction concept are



Kjellgren of Sweden



Hotz of Switzerland,





Heath of Australia and
Nance, Hoyd, Dowel and Mayne of the United States.

17



Nance presented clinics on his technique of
“progressive extraction” in 1940 and has been
called as the father of “serial extraction”
philosophy in the United States.



Kjellgren in 1940 termed this extraction
procedure as “planned” or “progressive”
extraction procedure of teeth.

18



Hotz named the same procedure on “Guidance of
eruption”.



According to him the term guidance of eruption is
comprehensive and encompasses all measures
available for influencing tooth eruption.

19



Widespread adoption of serial extraction :



source of concern to all Pedodontists



its limitations as well as of its possibilities.



The principle reason is that its application involves

growth prediction.

20



Every serial extraction diagnosis is based on the
promise that future growth will be inadequate to
accommodate all of the teeth in a normal

alignment.

21

 Has

it foundations based on facts and
processes:
1. Tooth material-arch length deficiency
2. Physiologic tooth movement
3. Normal dental, skletal and profile
development

22



Predicting at an early stage, the lack of space in future
permanent dentition to accommodate all teeth

 Objective is to intercept arch length discrepancy
to reduce or eliminate the need of extensive appliance

therapy.
23

Serial extraction is based on two basic principles
 ARCH

LENGTH – TOOTH MATERIAL DISCREPANCY

 PHYSIOLOGIC

TOOTH MOVEMENT

24



As Nance (1940), Mooress (1963), Dewel (1954),

and others have pointed out,


After the eruption of the first permanent molars
at 6 years of age

25



If there is any change, it may be an actual
reduction of the molar-to-molar arch length,

26



The following is a list of possible, clinical clues
for serial extraction, occurring singly or in
combination:

27

 Severe

crowding with arch deficiency of 8-10

mm or more
 In

class I malocclusion with no skeletal

disproportions and showing harmony between
skeletal and muscular system with normal
overbite & good skeletal profile.

28

 Tooth

size jaw size discrepancy

 Absence

of physiologic spacing

29

 Lingual

eruption of permanent lateral incisor

30

 Unilateral

deciduous canine loss and shift to

the same side

31



Mal positioned or impacted lateral incisors that

erupt palatally out of the arch

32

 Abnormal

/ asymmetric primary canine root
resorption

33

 Labial

stripping, or gingival recession,
usually of lower incisor.

34



Mesial eruption of canines over lateral incisors.



Mesial drift of buccal segment



Abnormal eruption direction and eruption
sequence

35



Deleterious oral habits

Flaring,


ectopic eruption



Ankylosis etc.

36



Congenital absence of teeth providing space



Mild to moderate crowding



Deep or open bites



Severe Class II, III of dental/Skeletal origin



Cleft lip and palate



Spaced dentition
37



Anodontia / oligodontia,



Midline diastemia



Dilacerations



Extensive caries



Disportion between arc length and tooth material
which can be treated by serial extraction.

38



Psychological trauma can be avoided by treatment



Reduces the duration of the multi banded
treatment



Physiologically treatment
(as it involves the guidance of teeth into normal positions
making use of physiological forces)



Better oral hygiene

39

 Reduces

 More

cost of treatment

stable results

 Lesser

retention period is required.

40



Requires clinical judgment



Prolonged treatment time( 2-3 years)



Patient compliance( multiple visits)



Psychological trauma of extraction.

41



Possibility of developing tongue thrust



Arch length reduction



Ditching between canine and second premolar



Axial inclination should be corrected later.

42

Reversible phase

Irreversible phase

Done during
first transitory
period

second transitory
period

Extraction of
anterior
deciduous teeth

extraction of
permanent teeth

allow the alignment of
the permanent incisors,

correcting the crowding
of the posterior
segment
43

 1.

Proportional facial analysis :
According to Graber (1971), the face is
divided into,

Standard or orthognathic face i.e. the
relationship between

maxilla and mandible,

Are
Normal

maxilla and maxillary dentition
mandible and mandibular dentition and
maxillary dentition and mandibular dentition

44

2) Alveodental protrusion:


Class I maxillary mandibular alveodental protrusion:



The facial pattern is normal, dentition arc, relatively

forward.


This facial pattern responds well to Serial Extraction.



Class II maxillary alveodental protrusion:



The maxillary dentition is forward can be treated with
Serial Extraction in maxilla only.



Class III: Not suitable for Serial Extraction.
45

3) Alveodental retrusion:


Class I maxillary mandibular alveodental retrusion :

patients should be treated without extractions.


extractions create a dished in face.



Class II: Mandibular alveodental retrusion :



Serial Extraction not indicated.

46

4) Prognathism:
Class I Maxillary mandibular prognathism –
Indicated if,


teeth are severely crowded.



Because of the increase in size of jaws, extraction
usually not indicated.

47



Class II Maxillary prognathism :



fault in the maxillary base itself /



long anterior cranial base/



the cranial base being flat
(creating a downward and forward position of the
nasomaxillary complex)



Difficult to treat with Serial Extraction.

48

Retrognathism :


Class I maxillary mandibular retrognathism :



As the maxilla and mandible are replaced
relatively backwards, extractions are

contraindicated.

49



Class II mandibular retrognathism :



small corpus of mandible or small ramus or due
to excess vertical development of nasomaxillary
complex.



In such cases, the mandible rotates backwards
and creates an open bite.



Not a good case for Serial Extraction

50

I. EXAMINATION AND CONSULTATION

II. DIAGNOSTIC RECORDS
o

Photographs

o

Radiographs

o

Study models

o

Essential analysis

51

 Evaluation

of craniofacial and dental

relationship and proportions before treatment
 Assessment

of soft tissue profile

 Proportional

facial analysis

53



Monitoring of treatment progress



Detecting and recording muscle imbalance and

balance


Detecting and recording facial asymmetry



Identifying patients

54



Complete series of periapical radiographs or a
panoramic radiograph.

55

Must be taken for ---

Calculation of the total space analysis



Detection of supernumerary teeth



Evaluation of the dental health of the permanent
teeth, especially the first molars



Detection of pathologic conditions in the early
stages

56



Detection of evidence of a tooths size jaw size
discrepancy such as the resorptive pattern on the

mesial of the roots of the primary canines


Determination of the size, shape and relative

position of the unerupted permanent teeth


Evaluation of the eruptive patterns of unerupted

permanent teeth

57



Dental stage of the patient by assessing the length
of the roots of permanent unerupted teeth



Root resorption before during and after treatment



Final appraisal of the dental health after
orthodontic treatment

58



Evaluation of craniofacio - dental relationships

before treatment


Assessment of the soft tissue matrix



Classification of facial pattern.

59



Essential analysis include:

1.

Arch lenth

2.

Space available and

3.

Profile

4.

Total space analysis

60



Arch length analysis:
Determines the amt of spacing / crowding and
where it exists in dental arches.



Dental development analysis:
When teeth are likely to erupt



Profile evaluation:
Facial pattern

61



Assess and record



the dental anatomy



the intercuspation



arch form



the curves of occlusion

62



Evaluate occlusion with the aid of articulators



Measure progress during treatment



Detect abnormalities (eg. localized enlargement,
distortion of arch form)

63



Calculation of tooth size jaw size discrepancies.



Determination of mandibular rest position.



Prediction of growth and development

64

 Profile

: convex

 Lips

: anterior to line drawn from
nose to chin

 Overjet

: < 5mm

 Overbite

: < 30mm

 NO

of teeth,

size & shape
 Developmental

: normal

pattern : symmetric.
65



3 areas: anterior, middle & posterior and resulting
values for each area were added together to yield
final deficit.

Anterior area:


Calculation is done btw space required and space
available



Sp available: Includes Tooth measurement and Ceph

correction+ soft tissue modfn.

66



Tooth analysis



Measurement of mandibular incisors on cast were
added to the values obtained from the

radiographic measurement of canines.



Ceph’ correction: Calcltd acc to tweed’s method.

67



Instead of measurements being made of the dist on
the occlusal plane, btw the objective line and the
line indicating the true axial inclination of the

mandibular incisors,



The actual FMIA was subtracted(in degrees) from

the proposed angle and the difference was
multiplied by a constant(0.8) , to give the
difference in millimeters.

68

Soft tissue modf’n:


Thus teeth jaws, and soft tissue are all involved in
assessment.



It is done by measuring the Z angle of Merifield and
adding ceph’ corr’ to it.

70

If the correctd, Z angle was grtr than 8o*,

then mandibular incisor inclination was
modified as
necessary(upto an IMPA of approx 92*)

If the corrected angle was less than 75*,
add’nl uprighting of the mandibular incisors
was necessary.

71



Upper lip thickness was measured from the
vermillion border of the lip to the greatest
curvature of the labial surface of the central

incisor.



Total chin thickness was measured from the soft
tissue chin to the N-B line.

72

If lip thickness was greater than chin
thickness

the diff was determined and multiplied by 2
and added to space req’d

If it was less or equal to chin thickness, no soft
tissue modificationn was necessary

73



There is no definite “recipe” for this
procedure- Rudolf Holtz

74

If canine is erupting faster
than premolar

then enucleation of first
premolar can be done.

Or extraction of 2nd
deciduous molar followed by
lingual arch space maintainer
83

8-9 YRS
C extracted
After 1 year
D are extracted
Eruption of 4 is accelerated
Erupting 4 is extracted

Canines erupt in alignment

97

8 YRS
All D are extracted
C are maintained to retard the erupt’n
of perm’ Canines
After 4 -10 months
Extract all four erupting 4 along with
four C
Canines and incisors are aligned
98

Extraction of all D
Extraction of all 4’s
Extraction of all C’s
Canines erupt in
alignment
99

Premature loss of mandibular primary canine.


Usually accompanied by midline shift if



skeletal, dental , and profile patterns
overjet, overbite, axial inclinations,
normal

and number, size , shape,
developmental pattern


5-10mm or more arch length discrepancy
100

 Remaining
 If

primary canine should be extracted.

1st premolar root is formed more than half,

primary 1st molar extracted.
 Then,

1st premolar extracted as they emerge.

 Extraction

should be symmetrical.

101

 A-N-B

angle: 2 to 5˚

102

 Mandibular

plane angle( S-N-Go-Gn) :30-36 ˚

103

 Incisor

mandibular plane angle( IMPA): 93-100 ˚

104

 Mandibular

incisors in front of A-Pog line

105

 Maxillary

incisors to S-N line: 110-115˚

106

If 5 mm
discrepancy
per
quadrant.

( Dewel’s
method)Firs
t extract
primary
canines

When, first
premolar
roots are
formed more
than half,
extract 1st
deciduous
MOLAR

Then
extract 1st
premolar
as they
erupt.

108

Discrepancy of
6-10mm
Seen where
crowding is
more in canine
premolar
region

Or with bimaxillary
protrusion

Objective
should be to
eliminate the
first premolars
as soon as
possible.

109

•Extract primary first molar

1
2

•Allow 1st premolar to erupt before
canine

• Extract 1st premolar & primary
canine

110

 Extract

 Then,

primary molars and

enucleation of first premolar at the

same time

111

 In

this situation,

 Enucleation

of second premolar rather than first

premolar should be considered.

112



Depends on type and severity of open bite



If open bite is dental, sequence will be similar
to others.



If skeletal, most posterior teeth in dental arch
should be extracted.



Includes extracting of enucleating permanent
molars or second premolar.
113

 Overbite

will increase after a serial

extraction.
 So

not indicated.

114

 It

should be planned according to its severity

and type.
 If

not it will worsen the problem.

115

 Normal

overjet
 Minimal overjet
 Severe overjet

116



If no mandibular crowding present,



Then management is by eliminating maxillary
crowding

117



Extract maxillary primary canine



Then extract primary first molar



Later maxillary first premolar is
extracted.

118

 canine

 Molar

interdigitation- Class I

second molar interdigitation: class II

119



If crowding present in both maxillary &
mandibular arches Extract maxillary primary 1st molar
& Mandibular primary 2nd molar


Then, enucleation of permanent

mandibular 2nd molar.


Then, when maxillary 1st premolar erupt,
it is extracted along with maxillary

primary canine.

120

 This

requires concurrent orthopedic

appliance along with serial extraction.

121

 Skeletal

class III malocclusion

- Poor candidates

122



With anterior cross bite and functional slide.



E.g. primary mandibular canine in cross bite with
maxillary lateral incisor it can be extracted.



Once cross bite is corrected serial extraction is
stopped.

123

 Root

paralleling

 Inadequate
 Spaces

buccal digitations

remaining unclosed

 Excessive
 Skeletal

overbite & overjet

and profile disharmony

 Anchorage

consideration
124

 The

most frequently used orthodontic
appliance with serial extraction are:

 Maxillary
 Fixed

and mandibular lingual arches.

or removable headgears.

 Removable

Hawley appliance.

125



Effect of serial extraction alone on crowding:
relationships between tooth width, arch length,
and crowding.



Maxillary dental casts from 32 subjects who had
undergone only serial extraction were analyzed at 3
stages: before deciduous canines extraction, after
first premolars extraction, and at the end of the
observation period.
126



These results suggest that tooth width and arch length
discrepancy might preferentially affect the degree of
anterior crowding in cases of severe crowding.



There was no aggravation of the average crowding level
during the observation period in the present study.



The present study quantitatively suggested that serial
extraction was useful for the purpose of correcting
crowding in most cases.

127



Serial extraction of first premolars-postretention
evaluation of stability and relapse.



Cases evaluated: 30 patients who had undergone serial
extraction of deciduous teeth plus first premolars
followed by comprehensive orthodontic treatment and
retention.



Diagnostic records were available for the following
stages: pre-extraction, start of active treatment, end

of active treatment, and a minimum of 10 years postretention.
128



All cases were treated with standard edgewise
mechanics and were judged clinically satisfactory
by the end of active treatment.



Twenty-two of the 30 cases (73%) demonstrated
clinically unsatisfactory mandibular anterior
alignment postretention.

129



Intercanine width and arch length decreased in 29
of the 30 cases by the post-retention stage.



There was no difference between the serial
extraction sample and a matched sample

extracted and treated after full eruption.

130



This reports a case treated by a serial extraction
program at the mixed dentition stage followed
by a corrective orthodontic treatment, with a

long-term follow-up period.

131



20 yrs after the interceptive treatment, a
harmonious face was observed along with
treatment stability in the anterior posterior

direction, deep overbite(which has been
mentioned as a disadvantage of the serial
extraction program), and a small relapse of

anterior tooth crowding.

132



These conditions : normal occurrences for most
orthodontic treatments with a long-term follow-up
period.



THUS, establishment of a serial extraction

protocol determined relevant esthetic changes
that afforded an improvement of the patient's
self-esteem, with a positive social impact.

133



Furthermore, the low cost ,permits the use of
this therapy with underprivileged populations.



It is important to emphasize that an early
correction of tooth crowding by this protocol
does not guarantee stability, but small relapses
do not invalidate its accomplishment.

134



Has its both advantages and disadvantages.



Diagnostic skill, knowledge and experience are
critical.

“ SERIAL EXTRACTION IS NOT PANACEA FOR ALL

CROWDED ARCHES”
135

Serial extraction

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