CASE REPORT

Orthodontics

Serial Extraction of Abstract

First Premolar in || Brief Background

Class I Malocclusion:
Serial extraction is a technique advocated for use by Kjellgren
in 1947 due to a shortage of orthodontists at the time. This
form of treatment was intended to facilitate the treatment of

A Case Report orthodontic cases by general dentists to minimize the demand

upon the orthodontist. The purpose of this article is to show
the value of serial extractions in a young patient with severe
crowding

|| Materials and Methods:

A 9 year old pre-pubertal patient reported to the department
of orthodontics for regular dental check up. Deciduous molars
were in flush terminal plane, overjet and overbite of 1mm each
was present. All the primary canines were exfoliated, along with
right side lower deciduous 1st molar, there was no space for the
permanent canines to erupt and TANAKA JOHNSTON MIXED
DENTITION ANALYSIS showed 6.5mm of potential crowding.
There was palisading appearance of lower lateral incisors. .

|| Discussion
The patient’s treatment included serial extractions. The
treatment resulted in improved aesthetics, good arch alignment,
and occlusion with Class I molar relationship, ideal overjet, and
overbite.

|| Summary and Conclusions:

This case demonstrated that despite the criticism some may
direct toward this interceptive technique, good clinical results
can be achieved in carefully selected cases.
Dr. Vikas Sehgal
Professor and Head
|| Clinical Significance:
Correspondence Address There are certain clinical situations when treatment planning
Department of Orthodontics involving the use of serial extractions can prove beneficial to
and Dentofacial Orthopedics young patients.
DAV (C) Dental College
Yamunanagar, Haryana || Key Words
Serial extractions, extractions, orthodontics, crowding.

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|| Introduction right side w.r.t. upper dental midline. All the primary
Serial or guided extraction is the removal of certain canines were exfoliated, along with right side lower
         deciduous 1st molar, there was no space for the
sequence. The term guidance of occlusion is even permanent canines to erupt and TANAKA JOHNSTON
more appropriate because clinicians are interested in MIXED DENTITION ANALYSIS showed 6.5mm of
         

  *  potential crowding. There was palisading appearance

current piece of literature describes a case of primary
crowding treated with serial extraction.
|| Case report
A 9 year old pre-pubertal patient reported to the
Department of Orthodontics for regular dental
check up having leptoprosopic facial form, grossly

of lower lateral incisors. Family history revealed that
the patient’s sister V.G. had Class I malocclusion with
severe upper and lower crowding. She reported to the
department at the age of 13 years and was treated
with all 4 permanent 1st pre-molar extractions.
Prioritized Problem List
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  molar
appropriate soft tissue facial balance, competent lips,
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average nasolabial angle, average mentolabial sulcus
crowding
and pleasant smile (Fig. 1).
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Treatment Plan
Goals of the treatment were:
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by planned reduction of tooth material leading to
space creation for permanent canines.
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parallelism
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Treatment Sequence
Step1: Correction of ectopically erupting 16 and

    

Fig.1: Pre-Treatment and Post Treatment Records of the patient

Halterman’s appliance was used for correction of
  
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16. Rt. primary maxillary second molar was banded
with soldered wire extending distally to the impacted
On intraoral examination, teeth present were 11, 12,
       
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16, 21, 22, 31, 32, 36, 41, 42, 46, 54, 55, 64, 65, 74,
distal extension. A bondable button was attatched
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plane, overjet and overbite of 1mm each was present.
Elastic chain was used from the occlusal button to the
There was premature exfoliation of primary canines
recurved hook to distalize impacted molar.
due to undermining resorption caused by permanent
lateral incisors and reduction of the supporting zone Step 2: Sequential Extraction Protocol (Serial
due to unusual root resorption and caries in left Extractions)
deciduous 1st molar, therefore leading to crowding. <Z

    *  
Upper dental midline was coinciding with facial      
midline; lower dental midline was shifted 2 mm to the molars, when the root development was half way

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 complete, indicating accelerated eruption rate. It took
approximately 10 months for the pre-molars to erupt.
Following this Nance holding arch was placed in the
upper arch to maintain the arch length. All deciduous
second molars were exfoliated except lower left
deciduous second molar. This was extracted, mainly
for two reasons, the root development of the second
pre-molar was two-third complete and presence of



overjet, and overbite achieved. Soft tissue revealed an
improvement in the naso-labial angle and reduction
in the degree of convexity. The patient’s smile was
improved (Fig.1). Table-1 gives a brief comparison
of important pre-treatment and post treatment
cephalometric values.
Retention
 
 Upper Hawleys appliance was given for 2 months to
pre-molar. allow further settling of occlusion. After that it was
Extraction of 1st

replaced by upper vacuum formed retainer. Lower
arch was stabilized by bonded lingual retainer from
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canine to canine.
permanent canines, whose roots were more than two
third developed, i.e., the eruption of the permanent


    >  _st pre- || Discussion
molar was also subsequently extracted. In more modern times there has been a resurgence
of interest in serial- extraction procedures. The
Treatment Results 
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Dentally, the maxillary and mandibular arches were Kjellgren in 1929.[1] Rudolph Hotz, on the other hand,
aligned. The Class I molar and canine relationships, referred to the procedure as guidance of eruption.

Table 1: Comparison of Pre-Treatment and Post Treatment Cephalometric Values

Parameters Normal values Pre treatment values Post treatment value

SNA 82+/-20 780 790
SNB 80+/-20 740 760
ANB 2+/-20 40 30
JARABAK RATIO 62-65% 58.9% 58.6%
0 0
FMA 25 25 240
0 0
BASAL PLANE ANGLE 25 25.5 24.50
OCCLUSAL CANT 9.30 50 40
U1-PP 110+/-50 1140 1130
0 0
UI-NA(º/mm) 22 /4mm 20 /2mm 230/2mm
IMPA 900 880 850
0 0 0
L1-NB(º/mm) 25 /4mm 24 /5mm 20 /2mm
0 0
INTER-INCISAL ANGLE 131 +/- 5 132 1400
NASO-LABIAL ANGLE 102+/-40 1030 1010
E-LINE
A. Upper lip -2 to –4 mm -2 mm -1mm
B. Lower lip -1 to –2 mm -2 mm -1mm
S-LINE
A. Upper lip 0 mm 0mm -1mm
B. Lower lip 0 mm -1mm 0mm

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[2]
Charles Tweed and many others found that serial 

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extraction, especially in Class I tooth-size/jaw-size resulting in premature exfoliation of primary second
discrepancy malocclusions, improves the alignment molars.
of the teeth when they emerge into the oral cavity.[3]

 
 

Tod Dewel, Hayes Nance, John Heath and Z. Bernard
Lloyd followed much the same route for their mixed Secondary crowding is an acquired anomaly due
dentition guidance.[4,5] The following two possibilities to environmental reasons. Most common reasons
  




     include: trauma, iatrogenic treatment, interproximal
* 

 






 caries, premature exfoliation of primary teeth with
  
 
    

 
 subsequent drifting of permanent teeth, prolonged
and, occasionally, even between the second and third
molars. This second molar area should not be ignored
in any extraction decision, serial or otherwise. If a space
retention of lower primary second molar and ankylosis
of primary teeth.
Most favourable conditions for serial extraction
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 include:
molars, then this should be considered in any arch-
length evaluation, for it usually means that the lower + ?

  

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         length discrepancy
assurance that they will retain their new positions. + @ 
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facial pattern
The positions of the lower incisors comprise the
second neglected area in determining whether the + @   
arch length can be increased. These incisors may relationship of the second primary molars
be spaced, or they may present an excessive lingual + 'ƒQ
inclination beyond the range of normal variation. + 'ƒ
The usual cause is premature loss of deciduous
Dewel, Lloyd, Kjellgren, Tweed, and other pioneers
canines, either by natural means or by ill-conceived
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serial extraction. Here again, arch length often can
serial extraction, and they more or less agree on its
be increased by closing the incisor spaces and by
advantages and disadvantages.[1,3,6] The advantages
uprighting these four lower anterior teeth. For these
mentioned most often in their writings are that serial
reasons, every arch-length evaluation must include a
extraction permits physiologic tooth movement,
consideration of positions of second molars and of
reduces appliance therapy and shortens the period
the four incisors.An impossible situation exists with
of retention. Other advantages are that the load on
true hereditary tooth size/jaw size discrepancy which
anchorage units is decreased and that there is less
cannot be compensated by interdental spacing, an
disturbance of alveolar bone and of periodontal
increase in intercanine arch width or labial positioning
structures. The disadvantages include increased
of permanent incisors.
overbite, lingual tipping of incisors, scar tissue in the

   
 extraction space, diastema, and alteration of tongue
Signs of primary or hereditary crowding include function.
disproportionately sized teeth and jaws, absence of
interdental spacing, unilateral exfoliation of primary || Conclusion
canines leading to midline shift, bilateral premature Serial extraction procedure is not easy and proper
exfoliation of primary canines leading to lingual tipping diagnostic assessment with careful monitoring is the
of incisors, crowding/rotations in incisor segment, key factor.
lingually placed/ blocked out lateral incisor, splaying
out of permanent maxillary or mandibular incisor teeth +  ‚
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caused by crowded malposition of unerupted canines, + ' ? 

  

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capable of producing extensive amount of
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permanent tooth translations.
mechanotherapy.
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health of investing tissues must be considered as + &    
they continually impact the occlusal guidance. follow a regular regimen.

Co-authors

Dr. Vishav Kirti Sharma Dr. Pulkit Lakhani Dr. Apoorva Sharma
Senior Lecturer P. G. Student Senior Resident
Maharaja Agrasen Hospital
West Punjabi Bagh, New Delhi

|| References
1. Kjellgren B: Serial extraction as a corrective procedure in 4. Graber TM. Serial extraction: a continuous diagnostic and
dental orthopedic therapy, EurJOrthod. 2007; 29:i37–i50 decisional process. Am J Orthod. 1971;60(6):541-75.
2. Hotz RP. Guidance of eruption versus serial extraction.Am 5. Mayne, Warren R.: A Concept, a Diagnosis, and a
J Orthod. 1970; 58(1):1-20. Discipline, D. Clin North America. 1959:281-288.
3. Tweed CH. Clinical orthodontics, vol 1. St Louis: C. V. 6. Dewel BF. Prerequisites in serial extraction.Am J
Mosby;1966. Orthod.1969;55:533-9

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