American Journal of ORTHODONTICS

and DENTOFACIAL ORTHOPEDICS

Founded in 1915 Volume 105 Number 2 February 1994

Copyright © 1994 by the American Association of Orthodontists

CLINICIANS' CORNER

Mandibular incisor extraction therapy

Joseph R. Valinoti, DDS*
New York, N.Y.

Extracting a mandibular incisor has been stigmatized as an expedient that may adversely affect the
occlusion. However, when properly used, the extraction is only one aspect of the total correction of
the malocclusion. Failure to observe this will fulfill the negative predictions. Articulating six maxillary
with five mandibular anterior teeth necessitates a visualization of the posttreatment occlusion, and
therefore specific criteria for case selection are essential. Treatment trends oscillate between
nonextraction and four premolar extractions, with perhaps insufficient attention currently given to
alternatives. This middle of the road approach is indicated in carefully selected cases, especially
where space requirements and facial esthetics do not call for greater dental movements. (AM J
ORTHOD DENTOFACORTHOP 1994;105:107-16.)

S e v e r a l approaches for crowded mandibular references to it, often as c a s e reports, 6m or as one of

anterior teeth are currently employed: distal movement
of posterior teeth, lateral movement of canines, labial
movement of incisors, interproximal enamel reduction,
removal of premolars, removal of one or two incisors,
and various combinations of the above. Selecting the
best treatment is often difficult, and all guidelines do
not apply to every case.
Even more vexing to the clinician is that no one of
these treatment plans can predict ultimate stability with
even reasonable certainty. Studies show a natural long-
term unpredictable tendency for mandibular intercanine
width to decrease in treated and untreated dentitions,
for bites to deepen, and for posterior teeth to move
forward for many years with recrowding of anterior
teeth. '~ These findings are at variance with some of the
previously mentioned treatment plans for crowding. It
does seem reasonable, however, to ask: "Are retainers
forever?"
REVIEW OF THE LITERATURE
No reports are available on the frequency of a man-
dibular incisor extraction, perhaps indicating its infre-
quency, or its infrequent reporting. However, there are
many possible approaches for crowding. ,-16 Others ad-
vise it for cases of anterior tooth size discrepan-
cies, ",17'~8 or to harmonize with an absent maxillary
lateral incisor.tg"2° Gingival hypertrophy in this area may
be another indication. 21
The prevailing opinion is to reserve the procedure
for the atypical, compromise, or relapse case, and even
then caveats are voiced regarding overjet increase,
space opening, and a compromised contour of the pa-
pillae. Increase in anterior overbite is the most frequent
warning. ~o.~o.2z
Tuverson is more optimistic. "Occasionally the
orthodontic treatment plan indicates extraction of a
lower incisor or space closure when a lower incisor is
missing. Because of the excellent results frequently ob-
tained, these are no longer considered 'closet cases.'
Although once looked upon as a 'dastardly act,' pro-
voking negative feelings similar to those encountered
when premolars were first extracted, the extraction of
one or even two lower incisors is becoming more com-
mon in orthodontic treatment and case presentations. ''t9
In conjunction with the extraction, he advises "accurate
mesiodistal enamel reduction of maxillary central in-
cisors" where indicated.

*Clinical Professor, New York University College of Dentistry, New York,
and Consultant. Catholic Medical Center of Brooklyn and Queens, New York.
Copyright © 1994 by the American Association of Orthodontists.
0889-5406194151.00 + 0.10 8/4/41184
SELECTION OF SUITABLE CASES
There are malocclusions with crowding of mandib-
ular anterior teeth that may be candidates for one incisor

107
108 Valinoti
Fig. 1. Case 1. Pretreatment facial and oral views (top and center). Completion of first phase (bottom).
extraction. As with every malocclusion, a visualized
treatment objective (VTO) is necessary, but in addition,
these cases require visualizing the atypical articulation
of six maxillary anterior teeth with five mandibular
anterior teeth. Certain criteria will aid in the selection
of suitable cases:
1. Treatment strategy will begin with accurate mea-
surements of required arch length and available arch
length in the entire mandibular arch, or tooth-size-arch-
length-discrepancy (TSALD). 4 A calculation will in-
dicate whether removal of an incisor produces harmony
between the two, or excess space or deficiency.
An assessment of available space will also include
both a consideration of the depth of the curve of Spee,
and the inclination of the lower incisors. Leveling the
curve of Spee and incisor uprighting, will require ad-
ditional space if these are indicated. 23
2. An additional consideration is the intercanine
width, and the effect of an incisor extraction on it.
Unless these teeth were originally ectopic, function and
future stability are best served if the width is main-
tained, 1,2 and a future natural decrease anticipated. 3,s
American Journal of Orthodontics and Dentofacial Orthopedics
February 1994
3. With six maxillary anterior teeth now articulat-
ing with five mandibular anterior teeth, the overbite
must be maintained or, if deep, reduced. Overjet is
likewise maintained or reduced to produce centric oc-
clusal contacts. Maxillary and mandibular canines will
finish in ideal Class I relations, or the distoincisal in-
clines of maxillary canines may occlude with the me-
sioocclusal inclines of mandibular first premolars.
Reference to the Neff Coefficient or the similar Bol-
ton Index and other guides will aid in determining max-
ilIary to mandibular tooth size discrepancies and asym-
metries. 11.17.24
These, in conjunction with TSALD, will indicate
whether the removal of the larger lateral incisor or the
smaller central incisor is indicated. Usually, removal
of the smaller central incisor is advisable. However, it
is our observation that the decision to remove a partic-
ular incisor because it exhibits dehiscence of its labial
gingiva is usually contraindicated, since the defect may
remain. A surgical repair is first performed and then
the decision made whether to remove the incisor with
the repaired gingiva, or another. The decision to remove
American Journal of Orthodontics and Dentofacial Orthopedics Valinoti 109
Volume 105, No. 2

r I!l N.L. O• 4 -
9 Y
87
0 M -- 13
3
Y
- 92
11 N

S N - Go Gn 31 o 30 o
S N A 78 o 76 o
/ S N B 73 o 73 o
. . ANB 5 ° 3 °
,"1----/------------7 Y; .
I-
.'i--
SN
Go Gn
102
B8
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"" CASE
Fig. 2. Case 1. Pretreatment and posttreatment superimposition on S-Na (left). Pretreatment and
posttreatment superimpositions; the maxilla on ANSopNS and the mandible on the symphysis and
mandibular plane (right).

an incisor in the presence of bony defects in this area
must be carefully evaluated.
A diagnostic set-up of both arches is informative if
performed with extreme accuracy, and often suggests
minor interproximal reduction of maxillary anteriors to
allow their retraction, alignment and maxillary to man-
dibular arch coordination. 8,t2'l~'~9'24,z~ However, Sheri-
dan warns that "stripping is an irreversible procedure
and should be initiated with this in mind. ''26
4. As with all ideal treatment, an objective will be
canine rise or posterior group function on the working
side, and an absence of cuspal interferences on the
nonworking side. The protrusive excursion will result
in posterior disclusion.
5. Dental esthetics will require proper positioning
in the sagittal plane of maxillary and mandibular an-
terior teeth, relative to the commonly used reference
lines. An interincisal angle in the normal range is a
major contributor to esthetics. However, standards for-
mulated for four mandibular incisors may not be ap-
plicable when only three are present.
Facial esthetics will require a reasonably accurate
prediction of the effects of growth and dental move-
ments. Two maxillary or four premolar extractions, or
nonextraction therapy, may affect the facial profile. A
lower incisor extraction in itself will not.
6. This modification of the anterior occlusion re-
quires consideration of the reciprocal reactions that may
occur in the posterior occlusion, and whether they are
desirable. There are instances where after alignment
and positioning of the three lower incisors, part of the
extraction space remains. This may be advantageously
used to mesialize posterior teeth in cases where one or
both buccal segments are in full or partial Class II
relation. If space exists where canines are in Class I
relationship, their slight additional mesial movement
for space closure will place maxillary canines in partial
occlusion with mandibular first premolars. This may be
110 Valinoti American Journal of Orthod;mtics and Dentofacial Orlh~gedics
Februao' 1994

Fig. 3. Case 1. Posttreatment facial and oral views.

Fig. 4. Case 2. Pretreatment ,acial and orai views.

American Journal of Orthodontics and Dentofacial Orthopedics Valinoti 111
Volume 105, No. 2

P. E. ~ 10 - B9 2 - 92
13 Y 11 N-16 Y 3N

S N - Go Gn 34 o 35 o
S N A 78 o 76 o
S N B 74 o 74 o
A N B 4 ° 2 °
- SN 88 o 101 o
* * -1-Go Gn 75 o 89 o
* * 1 -T 165 o 135 o
1 - N P 3 mm 5 I!=11

j/
%
%

CASE 2

Fig. 5. Case 2. Pretreatment and posttreatment superimpositions on S-Na (left). Pretreatment and
posttreatment superimpositions; the maxilla on ANS-PNS, and the mandible on the symphysis and
mandibular plane (right).

preferable to esthetic bonding, which we have not found
necessary.
If these criteria are to be satisfied, orthodontic treat-
ment will rarely be in the mandibular arch only. If they
can be satisfied, the case may be a candidate for man-
dibular incisor extraction therapy.
7. The decision to extract is best postponed until
the early permanent dentition, when fewer dental and
skeletal variables are present. The concept of early pre-
molar removal is not applicable to mandibular incisor
removal. In addition, mechanotherapy is improved with
a full complement of teeth.
DISCUSSION
Treatment of the total malocclusion is primary, and
the removal of a lower incisor is only part of it. Yet
the "stigma" attached to this therapy has been notedfl a
and the references cited are predominantly negative,
arising perhaps from unfavorable experiences. These
may be the result of faulty case selection, faulty me-
chanics, or mechanics suitable for other extractions,
but not for a mandibular incisor. The ease and rapidity
of the extraction space closure and resulting alignment
may distract attention from the total requirements of
the malocclusion. The caveats regarding increase in
overbite are well taken if control of the vertical di-
mension is inadequate. However, in our experience, a
deep anterior overbite does not in itself contraindicate
this therapy.
The maxillary midline will overlie the remaining
central incisor. We do not believe that this absence of
a mandibular dental midline affects occlusion, esthet-
ics, periodontal health, or stability, the principal re-
quirements of orthodontic therapy.
Treatment options in the mandible are more limited
than in the maxilla, because of the predominantly cor-
tical bone, the mentalis muscle, and the absence of
sutures. In addition, facial and orbicularis muscles, to-
gether with the buccinator and the superior constrictor
of the pharynx, combine to form a continuous func-
1 12 Valinoti
Fig. 6. Case 2. Posttreatment facial and oral views.
tioning envelope which limits anterior, lateral, and pos-
terior movements. 27 If achieved, instability may fol-
low. 2"2s'29 Periodontal integrity, 29"3° and facial esthetics "-9
may also be negatively affected by expansion of anterior
teeth.
Interproximal enamel reduction (stripping), another
treatment alternative, has been advised by Peck and
Peck 3t "as an essential orthodontic treatment ingredi-
ent," and has gained popularity in recent years with air
rotor stripping. 26Questions have been raised concerning
the thinness o f lower incisor enameP 2"33 possible dam-
age to it, 34 and the need for its protection in a plaque
prone area. 3s Others have voiced concerns about re-
sorbing crestal bone and reducing space for the inter-
proximal papillaef1.34.36,37
Do mandibular incisor extraction cases exhibit less
recrowding after long-term retention? It is our clinical
impression that they do. This may be due to the main-
tenance o f teeth nearer their original positions where
muscle pressures are less likely to introduce instability.
Another possibility is the minimum stress on adjacent
anchorage during space closure, leaving all or most o f
American Journal of Orthodontics and Dentofacial Orthopedics
February 1994
the acquired space for the anterior correction. Riedel
has suggested that incisor extraction may give greater
stability in this area in the absence of permanent reten-
tion. 2° His most recent investigation confirms this. 38
Today's concern with stability indicates the need for
further research.
Four premolar extractions will continue to be the
optimum treatment for many malocclusions having
greater space requirements and the need for improved
facial esthetics. However, with careful selection and
management, there are cases that can be successfully
treated with a mandibular incisor extraction. This
approach will be a valuable addition to our armamen-
tarium.
CASE REPORTS
Case 1
The patient was 9 years old at the start of appliance
therapy. Oral and model analysis showed a Class II, Division
1 malocclusion in the mixed dentition, with a 9 mm overjet,
a 50% overbite (Fig. 1), and a tooth-size-arch-length-dis-
crepancy (TSALD) of - 8 . 0 mm. The ANB angle was 5 °,
mandibular incisor to mandibular plane was 88°, and the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 105, No. 2
Fig. 7. Case 3. Pretreatment facial and oral views.
maxillary central incisor was 11 mm anterior to line Na-Po.
Lips were protrusive relative to the nose-chin ("E") line (Fig.
2).
The first phase treatment was designed to reduce overjet
and overbite and open spaces for permanent mandibular ca-
nines, where deciduous canines had exfoliated. Edgewise at-
tachments (0.022 x 0.028) were placed on all permanent
molars and incisors, and a progression of round stainless steel
Australian arch wires were placed. Light Class II elastics
retracted maxillary incisors. Earlier, cooperation with an ac-
tivator was inadequate, and therefore extraoral force was not
used in either phase. Overjet was reduced, and to test stability
of the spaces gained for mandibular canines no retention was
placed, and the spaces rapidly decreased (Fig. 1). The first
phase treatment was 12 months, followed by observation
without appliances.
The second phase treatment was begun when all teeth
other than second and third molars had erupted. All teeth,
except the lower right central incisor, which was extracted,
received edgewise attachments. Immediate closure of the ex-
traction space was begun before the natural resorption of the
labial and lingual cortical plates, which occurs rapidly in this
area and hinders closure. Simultaneously, maxillary and man-
dibular incisors were intruded, rotations corrected, and pos-
Valinoti 113
terior corrections made with light Class II elastics. Six max-
illary anterior teeth were interproximally reduced a total of
3.5 mm. Rectangular finishing arch wires (0.019 x 0.025)
were placed for maxillary incisor lingual root torque, and for
mandibular incisor lingual root-labial crown torque, with con-
tinuation of Class II elastics. Vertical elastics for canine seat-
ing were used for the final 4 months.
The second phase active treatment was 18 months. Re-
tainers are a maxillary Hawley appliance and a mandibular
bonded lateral to lateral incisor wire. Facial and intraoral
photographs were taken during retention (Fig. 3).
Case 2
The patient was 13 years 11 months old at the start of
appliance therapy. Dental analysis showed a Class II, Division
2 malocclusion, with buccal segments between Class I and
Class II, supraocclusion of both anterior segments producing
a deep overbite, and a mandibular TSALD of — 8.0 mm (Fig.
4). Cephalometric values were within acceptable parameters,
with the exception of the mandibular incisor to the mandibular
plane (75°), and the interincisal angle (165°). Lips were
slightly retrusive relative to the "E" line (Fig. 5).
The treatment plan was overbite correction by intrusion
of maxillary and mandibular incisors, rotation corrections
114 Valinoti American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

,fl
T.D. (~ 12 - 89 2 - 92
13 Y 2 H -- 15 Y 4 H

S N - Go Gn 32 o 31 o
S N A 83 o 77 o
S N B 77 o 76 o
t t
A N B G ° 1 °
] - SN 100 o 105 o
t t 1 - Go Cn 100 o 102 o
-~ 131 o 123 o
I - N P 13 mm i0 mmmm

CASE 5

Fig. 8. Case 3. Pretreatment and posttreatment superimposition on S-Na (left). Pretreatment and
posttreatment superimpositions; the maxilla on ANS-PNS, and the mandible on the symphysis and
mandibular plane (right).

with space gained by 3.5 mm of upper anterior interproximal
reduction and the extraction of a mandibular left central in-
cisor, and slight mesialization of mandibular buccal segments
to improve molar relations. Lingual root-labial crown torque
to maxillary and mandibular incisors was indicated.
These goals were achieved with full edgewise
(0.022 x 0.028) appliances, a progression of nitinol and
round stainless steel arch wires, and rectangular finishing arch
wires (0.021 × 0.025 maxillary and 0.019 x 0.025 man-
dibular). No extraoral forces or Class II elastics were used.
Vertical elastics for canine seating were used for the final 3
months.
The active treatment time was 29 months. Retainers are
a maxillary Hawley appliance and a mandibularbonded lateral
to lateral incisor wire. Facial and intraoral photographs were
taken during retention (Fig. 6).
Case 3 mandibular second molars; maxillary second molars and third
The patient was 13 years 2 months old. Dental analysis
showed a Class I malocclusion with 50% overbite, a 6 mm
overjet, and a mandibular TSALD of - 6 . 4 mm (Fig. 7).
Large maxillary central incisors partially compensated for
small maxillary lateral incisors. Significantcephalometrie de-
viations were an ANB angle of 6°, a mandibular incisor to
mandibular plane angle of 100°, and the maxillary central
incisor 13 mm anterior to the Na-Po line. Lips were slightly
protrusive relative to the "E" line (Fig. 8).
The treatment plan was intrusion of maxillary central
incisors, their retraction aided by their interproximal reduction
and the reduction of the mesial surfaces of maxillary canines
of 3.5 mm, mandibular arch length deficiency correction by
the extraction of the mandibular left central incisor, and in-
trusion of the five mandibular anterior teeth. Lingual root
torque to maxillary central incisors was indicated, as was
minor lingual root-labial crown torque to mandibular incisors,
to maintain their existing positions.
Edgewise attachments were placed on all teeth, including
molars were not attached. This was followed by a progression
of nitinol, round stainless steel and rectangular finishing
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 105, No. 2
• ' ~ ' ',
' ! :
:- ~. ,
Fig. 9. Case 3. Posttreatment facial and oral views.
arches. Class 1I elastics were used in conjunction with the
maxillary torque force, and vertical elastics to maxillary ca-
nines for cusp seating near completion.
The active treatment time was 26 months. Retainers are
a maxillary Hawley appliance and a mandibular bonded lateral
to lateral incisor wire. Facial and intraoral photographs were
taken during retention (Fig. 9).
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Reprint requests to"
Dr.Joseph R. Valinoti
66 Park Ave.
Manhasset, NY 11030

AAO MEETING CALENDAR

1994--Orlando, Fla., April 30 to May 4, Orange County Convention and Civic Center
1995--San Francisco, Calif., May 13 to 18, Moscone Convention Center
(International Orthodontic Congress)
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1997--Philadelphia, Pa., May 3 to 7, Philadelphia Convention Center
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