EXTRACTION IN ORTHODONTICS

Why to extract ?
In orthodontics, there are two major reasons behind extraction : 1.To provide space to align the remaining teeth in the presence of severe crowding 2.To allow teeth to be moved (usually incisors to be retracted) so protrusion can be reduced or so skeletal class II or class III problems can be camouflaged. 3.Caries and other pathology

Factors affecting the choice of extraction :
 Treatment objectives  Type of malocclusion  Esthetics (large chin button, prominent nose)  Growth pattern.  Conditions of teeth.(caries, multifilled teeth, impacted, ectopic, severe rotation)  Health of supporting tissues.

Controversy between extraction/non - extraction philosophy
The great extraction controversy of the 1920s

Edward Angle – Normal occlusion(1899). Facial esthetics and stability potential complications in his efforts to achieve an idealized normal occlusion He was influenced by philosophy of RousseauImperfections of modern man related to negative influence of civilization and that man could reach perfection with correct efforts..

Concepts challenged by Calvin Case. teeth aligned. Skeletal elements-accommodate teeth. inherently capable of having a perfect dentition. Deway won. Extraction never needed. 1902 article“My belief is that if we would confer the greatest benefits upon our patients from an esthetic stand point.overcome improper jaw relationship. .Bone growing appliance Relapse: Failure to achieve proper occlusion became his article of faith. neither esthetics nor stability would be satisfactory in the long term” Widely publicized debate – Dewey and Case. INFLUENCED BY WOLF LAW OF BONEThe architecture of bone responds to the stresses placed on that part of skeletal. Proper function of dentition is the key to maintaining teeth in their correct position. we must work hand in hand with nature and assist her to establish the relations of the teeth as the Creator intended they should be.& not resort to mutilation”. Rubber bands.Inappropriate to extract. His edgewise appliance . “Although arches could be expanded.( Article of faith for him) Every person had potential for an ideal relationship of all 32 teeth. Led Angle to 2 key concepts: • • • • • • • Skeletal growth influenced by external pressure.

extraction is considered necessary to accommodate the teeth to discrepancies in jaw position as well to overcome crowding caused by tooth-jaw discrepancies. . Charles Tweed: Retreated 100 of his patients with extraction of first four premolars and found stability of occlusion.  “Tooth extraction as an aid to orthodontic treatment is scientifically correct .but not always first premolars. 1930’s relapse frequently seen. extraction of second molars also advocated for the same reason.Popularized the view that the most effective extraction strategy to relieve crowding is to extract the premolar teeth closest to the site of crowding.Showed the evidence for benefit of extracting second premolars or even first molars to alleviate crowding but at the same time to reduce the degree of retraction of the anterior teeth.century By. lack of proximal wear.Led to over-retraction of anterior teeth in many cases. ”  By late 1940’s extraction treatment became more widely accepted.Reintroduction of extraction in mid.  By early 1960’s. more than half of American patients undergoing treatment had extraction of some teeth.  Since then .” Raymond Begg:  Attritional occlusion theory. More recently . It simulates the natural loss of tooth substance by attrition. Margolis : . Tweed: “It is my opinion that it is necessary to remove dental units in all those cases where there exists a discrepancy b/w tooth structure and basal bone. Carey and Williams: . . It led to widespread reintroduction of extraction in orthodonticsby the late 1940s.

Orthodontic treatment synonymous with extractions. Post displacement of condyles and TMDs  Recommended extraction of second molars  Studies concerning first premolars and TMDs. Jason and Hasund (Norway) 60 patients Dibbets Van der Weele (1991) 15 case study. Litigation: 1980s  TMD problems.  Witzig and Spahl. TMD . • No relation between choice of extraction . • • • • Distalization of mandible. The controversy continues and these range from an absolute rejection of the possibility of a need for extraction to a rejection of the possibility of arch expansion and growth guidance along with a continued high percentage of extraction. Later criticized Arguments continued throughout 1960s Prefer fuller and more prominent lips than std of 1950s and 1960s.Recent trend towards non-extraction:      Indiscriminate use of extractions.critical of bicuspid Xn. type of teeth . “Reality is somewhere between the two” Contemporary extraction guidelines: For orthodontic treatment in Class I crowding &/or protrusion : • Less than 4mmExtraction rarely indicated (only if severe incisor protrusion or a severe vertical discrepancy) .

Class II div 1 on skeletal class I + mild crowding.  Protraction of molars not required. What to extract ? Extraction of Ist premolars. INDICATIONS FOR 2ND PREMOLAR EXTRACTION: 1. ADVANTAGES :  Erupts before any other post teeth. 10mm/moreExtraction almost always.  Class I with bimaxillary protrusion.Good profile+mild crowding 2.• 5-9mmExtraction or non-extraction depends on • • • Hard and soft tissue characteristics. Ant & post crowding. Indications for 1st premolars extraction :  Convex profile with severe crowding.  Class II div I with deep anterior bite.  Center of each half of arch .  Class I with severe crowding.  Contact b/w canine and 2nd premolar satisfactory.flat profile+moderate crowding 3. after 6.  4 Xn adequate anchorage for retraction of 6 teeth.  Strategically located close to the incisors. Final position of incisors. .

8. Abnormal root morphology.dished-in) (rationale: farther back less facial change)  Open bite cases. Less possibility of buccal/lingual furrow in extraction space.Mild Class III inter-arch relation+mild crowding in U arch. ADVANTAGES :  Original facial contours retained without  reduction of lip profile.Congenitally missing.than a perfectly good premolar. 5. to preserve symmetry. Lesser tendency for extraction space to open in L arch. Easy correction of Class II molar correction to Class I  molar relation.  Multi filled teeth. 7. Grossly destructed/heavy restoration.4. . impacted.beyond restoration  RC Treated.     U 4 is more esthetic along side canine. . Open bite. 6.crown.  Facial considerations: Large chin buttons&/ prominent nose (4. 1st molar extraction INDICATIONS : Carious.  Premature Xn of 6.

• Crowding of lower arch minimized. Extraction of all Ist molars.  Min patient cooperation  Stable results. Non-cooperative pt. .  Profile maintained. Basis: • Additional space for eruption of 8s.  Class II div 1 active growth over.  Class II div 1 with mild open bite 6 extraction is avoided in:  Good molar relation.  Tuberosity not crowded.  Results similar to non-extraction. with some growth expectation.  U 4 occlude with L4  8s erupt normally.  Class II div 1 with good lower arch over basal bone.  Extraction duration is reduced. Single arch extraction – U 6 or what to do when non-extraction treatment fails  Class II div 1 with perfect lower arch alignment but growth expectation inadequate.Wilkinson’s Extraction: 1942 8 ½ to 9 ½ yrs.

ectopic. not apparent when patient smiles.  6 move distally in response to pressure.8. INDICATIONS: Chipman:  Xn 7 . rotated.AJO 1977 • • • Malocclusion due to potential force by developing 7.  Over compressed conn. ADVANTAGES AND INDICATIONS:  Disimpaction of 3rd molars. .caries.  Mild – moderate discrepancy with good profile.  Crowding in tuberosity area .2nd MOLAR EXTRACTION:  David W.Liddle. 4 extraction in treating the effect and not the cause.tissue fibers.move 3 &4 to a more normal occlusion. faster eruption  Prevention of “dished-in” at the end of facial growth  Prevention of late incisor imbrication  Facilitation of 1st molar distalization  Distal movement only as needed to correct the overjet  Fewer “residual”spaces at the end of Rx  Less likelihood of relapse  Good functional occlusion  Good mandibular arch form  Overbite reduction.with a need for distal movement of 1st molar. 10-12mm of space :Satisfies arch length problem. Extraction of 7s to intercept this forward force.

DISADVANTAGES:  Too much tooth substance removed in Cl I mal occlusion with mild crowding.Lehman – preconditions  8 in favorable angulation 15-30*angle to the long axis of the 1st molar.  Normal in size/shape & root area is sufficient w.  Location far from area of concern.  9-20% missing 3rd molars. Halderson.  Possible impaction of 3rd molars even with 2nd molar Xn  Unacceptable positions of erupted 3rd molars –second.r.  No congenitally missing teeth. Huggins.7– impaction of 8. Xn before roots begin to develop  30*to the occlusal plane  3rd molars in close proximity to 2nd molar-drift. late stage of fixed therapy. : Angulation. Lehman and Smith: Before radiographic evidence of root formn.(12-14yrs) Consensus opinion: As soon as 2nd molar erupts.  No help in correction of A-P discrepancy without patient cooperation . . 3RD MOLAR EXTRACTION:  Xn to prevent lower anterior crowding?  Distal movement of 6. Timing for mandibular 2nd molar extraction: Kokich:  3rd molar crowns completely formed.t 2nd molar.

INCISOR EXTRACTION: Advantages:  Maintains/ reduces intercanine width  General arch form is maintained – greater stability  Retention period.less . 1 incisor can be removed.therapeutic value • 1 sign of incipient malocclusion • Difficult to treat as they relapse easily. Disharmony b/w Occlusal planes. abnormal overbite Incisor extraction: Indications For mandibular incisors:  Extreme crowding / protrusion.  Minimum facial change. Contraindications: 1st or 2nd molars are extracted.Treatment time reduced.  Reidel. st  Not a new idea.  Gingival recession & loss of overlying bone on labial surface.  Jackson (1904)  Riedel : Extraction of 2 lower o Incisors-arch form without expansion of o intercanine width  Angle: Inexcusable. Xn of 8 before retracting.  Rarely-discrepancy in sizes of U & L incisors themselves.  Lateral incisors severely # in young children. Incisor Extraction:  Mandibular incisors.

Space closure quick. Anterior segments can be retracted readily if need be.  Long path of eruption.  Colour difference of canine. .  Easy reduction of overbite.  Gardiner et al: U crowding. Disadvantages :  Re-opening of space : Central Incisor. Extraction of Canines:  Not extracted: Affects profile.  Bu/Li blocked out lateral.  1 incisor extraction causes deepbite if normal tooth size relationship is present before Xn.  Reidel.  Congenital missing of 1 lateral incisor  Dilacerated tooth. Incisor extraction is –  Rarely indicated.  Unfavorable impaction of U incisor.intrusion. reshaping  Mechanotherapy is simplified.2 mandi incisors extracted to maintain intercanine width. with good contact b/w central and canine. mesial displacement of root apices of upper canine: Extraction of lateral incisor.  Danger of creating a tooth size discrepancy.  Immediate solid tooth support of entire buccal segments.

T. Vanarsdall . Tweed Orthodontics for Dental Students. Conditions where indicated:  Impossible to bring in alignment. T.  4 in contact with 2 & does not show palatal cusp.1977 rd rd rd nd nd th P. T. R. Begg. greater the resistance to movement. Leighton A text book of Orthodontics. M. B. Gardiner. H. J. L. AJODO. Graber Clinical Orthodontics. Current Principles and Techniques. vol. William R.  Efficient mechano therapy. P. 2 edn. Charles H. David W. T. C. The Effect of Different Extraction sites upon incisor retraction.(Raliegh Williams et al AJO 1976)  Relation b/w root surface area and extraction site selection upon incisor retraction. REFERENCES         Contemporary Orthodontics. Proffit Begg Orthodontic Theory and Technique. 4 edn. Principles and Practice.  Larger the root surface area. Kesling R.  Gross displacement Bu/Li . Foster Second molar extraction in orthodontics. 3 edn. White. D.1 . Graber. 3 edn. Liddle. C. treatment objectives. CONCLUSION: Orthodontic treatment may include extractions of any tooth in the arch based on sound diagnosis. C. 2 edn. 3 edn. M.  Diagnostic line.