School of Dental Sciences

Bharatpur, Chitwan, Nepal

Extractions in orthodontic
treatment

Dr Ajay Chhetri
Department of Orthodontics and Dentofacial Orthopedics-
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Introduction
• Certain sound healthy teeth may have to be sacrificed to facilitate
proper alignment of other teeth in cases of some orthodontic
treatment.

• Such extraction of sound teeth for the purpose of orthodontic

treatment is called as THERAPEUTIC EXTRACTION.

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History
• The role of extractions in orthodontic treatment has been a
controversial subject for over a century.

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ANGLE
• Believed that everyone had the capacity to have 32 teeth in functional
occlusion.

• Believed 32 teeth will provide the best aesthetics for each individual
therefore believed in expansion.

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Calvin Case
• Strongly criticized Angle’s Non – extraction approach because of its
effects on aesthetics i.e. excess dental protrusion following extreme
expansion and stability.

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Re – Introduction in 1940,s
• CHARLES TWEED disappointed with relapse – retreated 100 cases
with extraction of 4/4 and observed that the occlusion was much
stable.

• Independently of tweed RAYMOND BEGG in Australia concluded that

non – extraction treatment was unstable.

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• Extraction debate reopened again.

• Profit in 1994 gave a 40 years review of extraction frequency

1953 - 30 % had extractions
1968 - 76 % had extractions
1993 - 28 % had extractions

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Need for Extraction
• Arch length –tooth material discrepancy
• Correction of sagittal inter-arch relationship
• Abnormal size and form of teeth
• Severe skeletal jaw malrelations

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Choice of teeth for extraction

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Evaluation of diagnostic elements for
extraction

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Extraction of Ist premolars.
ADVANTAGES :.
• Center of each half of arch
• Anterior & posterior correction.
• Protraction of molars not required.
• Adequate anchorage for retraction of 6 teeth.
• Contact between canine and 2nd premolar satisfactory.

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Extraction of Ist premolars.
Indications for Ist premolar extraction:
1.Convex profile with severe crowding.
2.Class II div I with deep anterior bite.
3.Class I with severe crowding.
4.Class I with bimaxillary protrusion.

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Extraction of 2nd premolars:
INDICATIONS FOR 2ND PREMOLAR EXTRACTION
1.Good profile+mild crowding
2.Open bite.
3.Class II div 1 on skeletal class I +mild crowding.
4.When 4-5 mm of anchorage loss is desired.
5.Impacted.
6.Grossly destructed/heavy restoration.
7.Abnormal root morphology.
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ADVANTAGES :

1. Original facial contours retained without reduction of lip profile.

2. Upper 1st premolar more esthetic along side canine.
3. Easy correction of Class II molar correction to Class I molar relation.

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Ist Molar Extraction:
• Avoided:
Not provide adequate space in the ant region.
5 & 7 may tip in the extraction space.
Deepening of bite.
Masticatory efficiency.

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Indications:
• Minimal space required for anterior crowding.
• Open bite case
• Carious- beyond restoration
• RCT treated, - than a perfectly good premolar.
• Multi filled teeth- crown.
• Extruded molars.

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Wilkinson’s Extraction: 1942
 8 ½ to 9 ½ yrs. Extraction of all Ist molars.
 Basis:
• Additional space for eruption of 8s.
• Crowding of lower arch minimized.

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Drawbacks
• Extraction of 1st molars offers limited space to relieve crowding.
• Adjacent teeth may tip towards extraction space.
• Adequate anchorage demand may be hampered.

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2nd MOLAR EXTRACTION:
ADVANTAGES AND INDICATIONS
• Disimpaction of 3rd molars, faster eruption
• Relieve impaction of second premolar.
• Prevention of late incisor imbrication
• Facilitation of 1st molar distalization
• Open bite cases

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Disadvantages:
• Too much tooth substance removed in malocclusion with mild
crowding.
• Location far from area of concern.
• No help in correction of A-P discrepancy without patient cooperation
• Possible impaction of 3rd molars even with 2nd molar Xn
• Unacceptable positions of erupted 3rd molars –second, late stage of
fixed therapy.
• 9-20% missing 3rd molars.

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Timing for mandibular 2nd molar
extraction:
1. 3rd molar crowns completely formed, extractions before roots begin
to develop.
2. 3rd molars in close proximity to 2nd molar-drift.
3. Before radiographic evidence of root form.(12-14yrs)

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3rd Molar Extraction:
• Extraction to prevent lower anterior crowding?
• Distal movement of 6,7– impaction of 8.
• Extraction of 8 before retracting.
• Malformed third molars that interfere with normal occlusion

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Incisor extraction:

Indications
 For mandibular incisors:
• In mild class III cases with lower incisor crowding.
• Gingival recession,caries & loss of overlying bone on labial surface.
• Extreme crowding / protrusion.
• Incisors completely out of arch.
• Lateral incisors severely fractured in young children
• Rarely-discrepancy in sizes of U & L incisors themselves.

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Incisor extraction:
Advantages:
1. General arch form is maintained – greater stability
2. Retention period- less.
3. Immediate solid tooth support of entire buccal segments.
4. Mechanotherapy is simplified.
5. Space closure quick.

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 Incisor extraction:

Disadvantages
• Reopening of space .
• Danger of creating a tooth size discrepancy.
• Deepbite- if normal tooth size relationship is present before
extraction.
• Color difference of canine.

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 Upper Incisor Extraction:
Rarely indicated
• Unfavorable impaction of Upper incisor.
• Buccally/Lingually blocked out lateral, with good contact b/w central
and canine.
• Congenital missing of one lateral incisor
• Grossly carious incisors.
• Trauma or irreparable damage to incisors by fracture
• Dilacerated tooth.

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Extraction of Canines:
• Usually not extracted as part of orthodontic treatment.
• May cause flattening of face, altered facial balance and change in
facial expression
• Makes canine guidance impossible.

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Conditions where indicated:
• Impossible to bring in alignment.
• Impacted canines that have erupted in unusual location.
• Decidious canines may be extracted as a part of serial
extraction .

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Department of Orthodontics and Dentofacial Orthopedics-
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Balancing Extractions
• Balancing extractions may be defined as the removal of a tooth on the
opposite side the same arch (although not necessarily the same) in
order to preserve symmetry.

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Compensating Extractions
• Removal of the equivalent tooth in the opposing arch to maintain
buccal occlusion.

• If the third molar is extracted in the right quadrant of the maxillary

arch then the third molar in the right quadrant of the mandibular arch
is also extracted.

• This type of extraction is called as compensatory extraction.

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Conclusion
• Orthodontic treatment may include extractions of any tooth in the
arch.

• So it should be performed based on sound diagnosis and treatment

objectives so that a desired treatment goal for the final position of
incisors within the facial profile can be achieved.

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Department of Orthodontics and Dentofacial Orthopedics-
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