EXTRACTION/NONEXTRACTION A Differential Diagnostic Decision ‘As an introduction to our topic, it is necessary to review some basic orthodontic concepts. First and foremost, orthodontics is a space management procedure. We use space which is available or we make space available to correct malocclusions. Because orthodontics is a space management procedure, orthodontist’s must thoroughly understand the concept of dimensions of the denture. You have heard Dr. Merrifield’s excellent paper on the Dimensions of the Denture. Remember, there are four dimensions. There is an anterior dimension, a posterior dimension, a vertical dimension, and a lateral dimension. Clinicians should adhere to these dimensions in the treatment of the patient who has normal muscular balance. THE ANTERIOR DIMENSION Teeth should not be pushed off basal bone in a forward direction. When this is done, an unhealthy situation for the teeth is created. Facial protrusion is also created. This patient wore appliances five years. Note the position of the teeth off their bony support. Observe the facial imbalance. Tweed defined the anterior limit of the denture for the specialty of orthodontics. He developed the diagnostic facial triangle and proved that one could improve facial balance as well as stability if the mandibular anterior teeth were uprighted over basal bone. Tweed knew that a patient who had a low Frankfort Mandibular Plane Angle might not need as much mandibular incisor uprighting as the patient with the higher Frankfort Mandibular Plane angle, but even in the low angle patient, the mandibular incisors should not be pushed forward of their original position in the patient with normal muscular balance. For the patient with normal muscular balance extractions are often necessary if the anterior limit of the denture is to be respected in the presence of significant anterior crowding and/or protrusion.THE POSTERIOR DIMENSION: The posterior area of the mouth seems to be disregarded by many clinicians. Teeth are driven back into this area with little thought given to how much space is available for them, Merrifield, Richardson and Leygard have given the specialty some very good guidelines about how much space is actually available. Observe this cephalometric x-ray and the tracing of a patient whose treatment was started without extraction. Now, observe the x-ray made eight months later and its tracing. Look at the second molars. They are hopelessly impacted. There is no way this patient can be treated without extraction if there is any respect for the posterior area of the mouth. Observe the patients x-ray and the tracing after treatment with second premolar removal. Facial balance was protected - and the second molars had room to erupt. Also, when discussing the posterior dimension of the mouth, keep in mind that when we talk of non-extraction treatment, we must maintain 32 teeth in the mouth. Third molars are teeth. The extraction of third molars is a therapeutic decision, and if a patient has to have third molars extracted, it is extraction treatment. THE VERTICAL DIMENSION Merrifield, Pearson, Schudy and many others have written extensively in the literature about the vertical dimension. All of us know that if the vertical dimension is increased in the posterior area of the mouth, a longer face is created. There is gingival display upon smiling. If maxillary posterior teeth are driven distally to correct Class II malocclusions when no space is available, there is a wedging open effect in the anterior vertical dimension that creates a longer face. Merrifield found that for every 1 mm of vertical expansion in the molar area, a 1.3 mm drop in anterior nasal spine occurred. Patients who need extractions but who are treated without them are very often expanded vertically. Point B drops down and back. Poor facial esthetics is the result. It is crucial to preserve the vertical dimension if stability as well as facial balance and harmony are the ultimate goals.THE LATERAL DIMENSION Lateral expansion is touted in many circles. Lateral expansion works if you believe in permanent retention. Strang, one of our specialty's pioneers, studied lateral expansion. Strang’s conclusion was that it was to be avoided at all costs. Study the 1981 article by Little, Wallen, and Riedel. The dentitions that exhibited the most relapse were, in most instances, the ones that had undergone mandibular cuspid expansion. In today’s world, we hear a great deal about expansion in the mixed dentition. Read the article by Little, Riedel and Stein in the May, 1990 AJO/DO about increasing arch length during the mixed dentition. They reported that early arch length expansion was a failure 87° of the time. Read and study the chapter on “Retention” by Joondeph and Riedel in the new fifth edition of Graber and Swain. Study the photos that illustrate the chapter. Note the expansion and subsequent relapse. The lateral dimension must be respected. Now that the basic concept of Dimensions of the Denture has been discussed, consider the so called “borderline” patient, If one exarnines these patients’ records very carefully, it becomes evident that they quite probably should be treated either with or without extraction. To quote Levern Merrifield, “It is a matter of differential diagnosis. If teeth are to be extracted, one must decide which extractions will best allow one to correct the malocclusion.” If you worry about extraction in the so called “borderline” patient, read the study done by Paquette, Beattie and Johnston which was published in the June, 1992 issue of the AJO/DO. In the study a sample of borderline patients treated without extraction was compared with a statistically similar sample treated with first premolar extraction. The authors’ concluded that there was nothing wrong with extraction in the so called “borderline” patient. Remember, in the sample, the teeth that were extracted were primarily first premolars, but most probably, these patients had midarch problems and should have been treated with second premolar extraction. The wrong teeth were removed and yet these patients weren’t “sick”. When a patient is subjected to orthodontic treatment, the resulting dentition should be stable, functional, healthy, and have a pleasing esthetic appearance. Every orthodontist has some problems with relapse. What one must not do is help these problems along by creating an unstable situation that is destined to relapse.The following patient records illustrate the point that many so called “vorderline” patients are not “borderline” at all. They should be treated with extraction of selected teeth. Observe the pretreatment facial photographs. The pretreatment cephalometric x-ray and its tracing confirm a good skeletal pattern with teeth upright over basal bone. Observe the posttreatment x-ray and its tracing. Note the protrusion that was created. Both the anterior and posterior limits of the denture were violated. Note the side views of the pretreatment and posttreatment casts. Observe the occlusion. The teeth don’t function, a Class I relationship remains on one side. On the composite tracings, note the downward and backward movement of point B due to anterior, posterior, lateral, and vertical expansion. Observe the smiling face. Note the gingival display. This patient's mouth was expanded anteriorly, posteriorly, vertically and laterally. ‘There was no respect for the dimensions of the denture. It is evident that after a careful differential diagnosis, teeth should have been removed. There is no stability of this treatment result, Many so called borderline patients like this one are patients who have midarch or posterior discrepancies. A good differential diagnosis will lead the clinician to the choice of extraction of teeth other than first premolars. Observe the composite tracings and the pretreatment and posttreatment facial photographs of this patient from whom third molars were extracted. The point is that there are 16 teeth in the mouth, other than the first premolars and the twelve anterior teeth, which can be chosen for extraction. Differential diagnosis is the key. Many in our specialty continue to try to “re-invent” the wheel. They loudly advocate expansion to accomodate all the teeth and state that the latest appliance innovation allows them to expand without fear of relapse. Their statements have no scientific basis. In fact, the weight of scientific investigation lies on the side of the orthodontist who believes in non-expansion. In the Winter, 1993 Angle Orthodontist, Luppanapornlarp and Johnston published a study of a clear cut sample of extraction patients compared to a sample of clear cut non-extraction patients. These authors concluded, like others before them, that there is a long term 2 - 3 mm arch length reduction for most patients. After discussing this arch length reduction, the author’s state “As a result, the extraction patients improved, whereas the non-extraction patients worsened; the between-treatment differences were statistically significant and large enough to 4allow the originally crowded and protrusive extraction patients to achieve parity with their much less severely affected non-extraction cohorts. Moreover, the extraction patients were treated without any mean collapse of the upper intercanine width, and, more to the point of this discussion, the non-extraction patients were treated without resorting to routine expansion. Given this conservative approach to treatment, our data may underestimate the arch-length reduction that would be seen following more aggressive non-extraction therapy.” ‘THE FACE Consider facial esthetics. Some say that if you extract teeth, you unfavorably change the face. A universal and simple guideline for balance of the lower face is that the profile line should bisect the middle of the nose. Orthodontists can influence the profile line’s relationship to the nose with treatment. If the lips are protruded, the profile line will lie outside the nose. The objective should be to reduce the protrusion and move the profile line into the nose. Like Tweed discovered, selected extraction to upright mandibular incisors is the only way this, can be accomplished. However, if the profile line is in the nose pretreatment, the objective should be to maintain facial balance and harmony. If this dentally crowded patient had been treated without extraction of premolars, a facial protrusion would have been the result. Second premolars were removed. The key words are differential diagnosis. Herb Klontz makes the statement that “good directionally controlled orthodontic treatment only preserves nice facial balance or improves poor facial balance.” Orthodontic treatment should never harm facial balance. Again, Luppanapornlarp and Johnston have some interesting comments about extraction and its relationship to the facial profile. They discuss the effects of extraction on the profile and make the following statement which is illustrated by the drawings of pretreatment, posttreatment and recall facial polygons. They state that “It should not be inferred, however, that the extraction profiles were too “flat” on recall. Instead, it was the non-extraction patients who tended to have concave faces, whereas the extraction patients more often had what non-extraction advocates might call “nice, full, pleasing profile’. Given the initial crowding and protrusion of the extracton patients (and the relative spacing and retrusion of the non- 5extraction patients), this result is unremarkable; it is mentioned at the outset merely to counter the popular notion that “dished-in profiles” are a unique, obligatory by- product of first-premolar extraction therapy.” Observe the illustration from their article. The recall profiles from the two samples were enlarged, and a profile line was drawn on each face. Note the relationship of the profile line to the nose on the respective faces. It has a much better relationship on the extraction face than on the non-extraction face. But the non-extraction face was not made flat by orthodontics. Heredity made it flat. The point is that proper orthodontic diagnosis and treatment does not have a deleterious effect on facial esthestics. These patients were treated with the removal of maxillary and mandibular first premolars. Notice the improvement in facial balance and harmony. This group of patients had midarch crowding, but balanced facial profiles. Second premolars were removed. This group of patients had facial imbalance and Class II occlusions, but upright mandibular incisors. The maxillary first premolars and the mandibular second premolars were removed. These patients were treated without premolar extraction, but third molars had to be removed. 1 believe Tom Graber summed it up accurately when he said, “The question is not whether we extract, the question is which teeth do we extract?” In summary, extraction is a wonderful tool for the orthodontist. The specialty must use it wisely, but I firmly believe it must use it. None of us should be extractionists or non-extractionists. We should be orthodontists - not tooth alignment specialists. We are specialists in space management. Without space to manage, we cannot give our patients a high quality service. Our ultimate goal is to give our patients the highest quality of service in the shortest period of time for the most reasonable fee. We cannot meet this goal if our treatment is determined by our bracket design, our ability or lack thereof to manipulate archwire, or our personal biases. We cannot create space by mixing braces, bone, saliva, and teeth. Orthodontics is a science as well as an art. We must use every tool at our disposal to give our patients a treatment result that is esthetic, healthy, functional and stable. We cannot do this if we eliminate our two greatest assets - a scientific differential diagnosis which may lead to necessary extractions, and our artistic ability.EXTRACTION/NON-EXTRACTION SELECTED BIBLIOGRAPHY Ades, A.G., Joondeph, D.R,, Little, RM. Chapko, M.K.: “A Long-term Study of the Relationship of Third Molars to Changes in the Mandibular Dental Arch.” American Journal of Orthodontics and Dentofacial Orthopedics, April 1990. Artun, J,, Krogstad, O,, Little, RM.: “Stability of Mandibular Incisors Following Excessive Proclination: A Study in Adults with Surgically Treated Mandibular Prognathism.” ‘The Angle Orthodontist, Summer 1990. Bjork, A., Gensen, E., Palling, M: “Mandibular Growth and Third Molar Impaction.” European Orthodontic Society Trans., 1956, pp. 164 Burstone, C. J: Application of Bioengineering to Clinical Orthodontics, Chapter #3, Graber and Swain, The C.V. Mosby Co., 1985, pp. 193-227. Dake, M.L,, Sinclair, PM. “A Comparison of the Ricketts and Tweed-type Arch Leveling “Techniques.” American Journal of Orthodontics and Dentofacial Orthopedics, January 1989, Drobocky O.B,, Smith, RJ: “Changes in Facial Profile During Orthodontic Treatment with Extraction of Four First Premolars.” American Journal of Orthodontics and Dentofacial Orthopedics, 1989, Vol. 95, pp. 220-30. Gebeck, T. R., Merrifield, L. Ls “Analysis: Concepts and Values,” Part I, Journal of the Charles ‘Tweed Foundation, 1989, Vol. 17, pp. 19-48. Gilmore, C.A, Little, RM.: “Mandibular incisor Dimensions and Crowding.” American Journal of Orthodontics and Dentofacial Orthopedics, December 1984, Hom, Andre’: “Facial Height Index,” American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 102, #2, pp. 180-186. Isaacson, R. J: “The Geometry of Facial Growth and its Effect on the Dental Occlusion and. Facial Form.” Journal of the Charles Tweed Foundation: 1981, #9, pp.21-38. Klontz, H. A: “Diagnosis and Force Systems Utilized in Treating the Maxillary First premolar and Mandibular Second premolar Extraction Case.” Journal of the Charles Tweed Foundation, April 1987, #15, pp. 19-57. Ledyard, B.C.: “A Study of the Mandibular Third Molar Area.” American Journal of Orthodontics, May 1953, Vol. 38, pp. 366-374. Little, RM.: “The Irregularity Index: A Quantitative Score of Mandibular Anterior Alignment.” American Journal of Orthodontics and Dentofacial Orthopedics, November 1975. Little, RM,, Wallen, TR, Riedel, R.A: “Stability and Relapse of Mandibular Anterior Alignment — First Premolar Extraction Cases Treated by Traditional Edgewise Orthodontics.” American Journal of Orthodontics and Dentofacial Orthopedics, October 1981. Little, RM, Riedel, R.A., Artun, J: “An Evaluation of Changes in Mandibular Anterior Alignment from 10 to 20 Years Postretention.” American Journal of Orthodontics and Dentofacial Orthopedics, May 1988.Little, RM,, Riedel, R.A., Engst, E.D.: “Serial Extraction of First Premolars - Postretention Evaluation of Stability and Relapse.” The Angle Orthodontist, Winter 1990. Little, RM, Riedel, R.A,, Stein, A.: “Mandibular Arch Length Increase During the Mixed Dentition: Postretention Evaluation of Stability and Relapse.” American Journal of Orthodontics and Dentofacial Orthopedics, May 1990. Little, RM, Riedel, R.A “Postretention Evaluation of Stability and Relapse - Mandibular Arches with Generalized Spacing.” American Journal of Orthodontics and Dentofacial Orthopedics, January 1989. Luppanapornlarp, S,, Johnston, L: “The Effects of Premolar-Extraction: A Long-Term ‘Comparison of Outcomes in “Clear-cut” Extraction and Nonextraction Class Il Patients.” The Angle Orthodontist, Winter 1993. McReynolds, D.C, Little, RM.: “Mandibular Second Premolar Extraction ~ Postretention Evaluation of Stability and Relapse.” The Angle Orthodontist, Summer 1991 Merrifield, LL: “The Dimensions of the Denture.” Unpublished paper presented at cach ‘Tweed Course - Charles Tweed Memorial Center, Tucson, Ariz. Merrifield, L. Li: “The Profile Line as an Aid in Critically Evaluating Facial Esthetics.” American Journal of Orthodontics, November 1966, #52, 11, pp. 804-822. Merrifield, L. L.: “Differential Diagnosis with Total Space Analysis.” Journal of the Charles ‘Tweed Foundation, 1978, #6, pp. 10-15. Merrifield, L. L,, Cross, J.J “Directional Force.” American Journal of Orthodontics, 1970, #57, pp. 435-464. Merrifield, L. L: “The Systems of Directional Force,” Journal of the Charles Tweed Foundation, April 1982, Vol. X, pp. 15-29, Merrifield, L. L.: “Edgewise Sequential Directional Force Technology.” Joumal of the Charles ‘Tweed Foundation, April 1986, #14, pp. 22-37. Merrifield, L. L,, Gebeck, T.R.: “Analysis: Concepts and Values," Part II, Journal of the Charles Tweed Foundation, 1989, Vol. 17, pp. 49-64 Paquette, D. E., Beattie, J.R,, Johnston, LE, Jr: “A Long-term Comparison of Non-extraction and Premolar Extraction Edgewise Therapy in “Borderline” Class Il Patients.” American Journal of Orthodontics and Dentofacial Orthopedics, July 1992. Pearson, L. E.: “Vertical Control in Treatment of Patients having Backward Rotational Growth Tendencies.” Angle Orthodontist, 1978, #43, pp. 132-40. Pearson, L. E.: “Vertical Control in Fully-Banded Orthodontic Treatment.” Angle Orthodontist, 1986, #56, pp. 205-24. Radziminski, G: “The Control of Horizontal Planes in Class II Treatment.” Journal of the Charles Tweed Foundation, 1987, #15, pp. 125-40. Richardson, M.E.: “The Effect of Mandibular First Premolar Extraction on Third Molar Space.” ‘The Angle Orthodontist, Winter 1989. Richardson, Margaret E: “The Relative Bffects of Extraction of Various Teeth on the Development of the Mandibular Third Molars”” Trans-European Orthodontic Society, 1975, pp. 79-85.Riedel, RA, Little, RM,, Bui, TD.: “Mandibular Incisor Extraction ~ Postretention Evaluation of Stability and Relapse.” ‘The Angle Orthodontist, Summer 1992. Riedel, RA,,Joondeph, DR: “Retention.” Orthodontics Current Principles and Techniques, Graber and Swain, Chapter 14. Rossouw, P. E,, Preston, C. B,, Lombard, C. J,, Truter, J. W: “A Longitudinal Evaluation of the Anterior Border of the Dentition.” American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 104, #2, pp. 146-152, August 1993. Sandusky, W.C.,IIl: “A Long-term Postretention Study of Tweed Extraction Treatment.” Unpublished Masters Thesis, University of Tenn., Center for the Health Sciences, June 1983. Schudy, F F: “Sound Biological Concepts in Orthodontics.” American Journal of Orthodontics, 1973, 463, pp. 376-97. Shields, TE, Little, RM., Chapko, M.K.: “Stability and Relapse of Mandibular Anterior Alignment: A Cephalometric Appraisal of First Premolar Extraction Cases Treated by Traditional Edgewise Orthodontics.” American Journal of Orthodontics and Dentofacial Orthopedics, January 1985. Sinclair, QM,, Little, RM.: “Maturation of Untreated Normal Occlusions.” American Journal of Orthodontics and Dentofacial Orthopedics, February 1983. Sinclair, QM,, Little, RM.: “Dentofacial Maturation of Untreated Normals.” American Journal of Orthodontics and Dentofacial Orthopedics, August 1985, Strang, R. H.: “Highlights of Sixty-four Years in Orthodontics.” The Angle Orthodontist, Vol. 44, 1974 Strang, R.H.W.: “The Fallacy of Denture Expansion as a Treatment Procedure.” Angle Orthodontics, 1949, Vol. 19, pp. 12417. ‘Tweed, C. H.: “Reports of Cases Treated with the Edgewise Arch Mechanism,” The Angle ‘Orthodontist, October 1932, Vol. 2, #4, pp. 236-243. ‘Tweed, C. H.: “The Application of the Principles of the Edgewise Arch in the Treatment of Class I, Division 1: Part I” Angle Orthodontist, 1936, #6, p. 256. ‘Tweed, C. H.: “The Application of the Principles of the Edgewise Arch in the Treatment of Class Il, Division 1 Malocctusion: Part 1.” Angle Orthodontist, 1936, #6, p. 198- 208. ‘Tweed, C. H.: “Indications for the Extraction of Teeth in Orthodontic Procedures.” American Journal of Orthodontics Oral Surgery, 1944, #30, pp. 405-28. ‘Tweed, C. H.: “A Philosophy of Orthodontic Treatment,” American Journal of Orthodontics Oral Surgery, 1945, #31, pp. 74-103. ‘Tweed, CH. “The Frankfort - Mandibular Incisor Angle (FMLA) in Orthodontic Diagnosis, ‘Treatment Planning and Prognosis,” American Journal of Orthodontics and Oral Surgery, July 1954, #24, pp. 121-169. ‘Tweed, C. Hz “Clinical Orthodontics,” Vol. land Vol. I, The C. V. Mosby Co,, St. Louis, 1966.