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..

Inappropriate to extract, inherently capable of having a perfect dentition.( Article of faith for him) Every person had potential for an ideal relationship of all 32 teeth. Extraction never needed. Skeletal elements-accommodate teeth.

1902 articleMy belief is that if we would confer the greatest benefits upon our patients from an esthetic stand point, 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.

INFLUENCED BY WOLF LAW OF BONEThe architecture of bone responds to the stresses placed on that part of skeletal.

Led Angle to 2 key concepts:

Skeletal growth influenced by external pressure. Rubber bands- overcome improper jaw relationship. Proper function of dentition is the key to maintaining teeth in their correct position.

His edgewise appliance - Bone growing appliance Relapse: Failure to achieve proper occlusion became his article of faith. Concepts challenged by Calvin Case. Although arches could be expanded, teeth aligned, neither esthetics nor stability would be satisfactory in the long term Widely publicized debate Dewey and Case, Deway won.

Reintroduction of extraction in mid- century

By, 1930s relapse frequently seen. Charles Tweed: Retreated 100 of his patients with extraction of first four premolars and found stability of occlusion. It led to widespread reintroduction of extraction in orthodonticsby the late 1940s.

Margolis :
- Popularized the view that the most effective extraction strategy to relieve crowding is to extract the premolar teeth closest to the site of crowding. - Led to over-retraction of anterior teeth in many cases. Carey and Williams: - 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. More recently , extraction of second molars also advocated for the same reason.

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.

Raymond Begg:
Attritional occlusion theory; lack of proximal wear. Tooth extraction as an aid to orthodontic treatment is scientifically correct . It simulates the natural loss of tooth substance by attrition. By late 1940s extraction treatment became more widely accepted. By early 1960s, more than half of American patients undergoing treatment had extraction of some teeth,but not always first premolars. Since then ,extraction is considered necessary to accommodate the teeth to discrepancies in jaw position as well to overcome crowding caused by tooth-jaw discrepancies.

Recent trend towards non-extraction:

Indiscriminate use of extractions. Orthodontic treatment synonymous with extractions. Later criticized Arguments continued throughout 1960s Prefer fuller and more prominent lips than std of 1950s and 1960s.

Litigation: 1980s TMD problems. Witzig and Spahl- critical of bicuspid Xn.

Post displacement of condyles and TMDs Recommended extraction of second molars Studies concerning first premolars and TMDs.

Distalization of mandible;

Jason and Hasund (Norway) 60 patients Dibbets Van der Weele (1991) 15 case study.

No relation between choice of extraction , type of teeth , TMD .

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. 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)

5-9mmExtraction or non-extraction depends on

Hard and soft tissue characteristics. Final position of incisors.

10mm/moreExtraction almost always.

What to extract ?
Extraction of Ist premolars.
ADVANTAGES :

Erupts before any other post teeth, after 6. Strategically located close to the incisors. Center of each half of arch ; Ant & post crowding. Protraction of molars not required. 4 Xn adequate anchorage for retraction of 6 teeth. Contact b/w canine and 2nd premolar satisfactory.

Indications for 1st premolars extraction : Convex profile with severe crowding. Class II div I with deep anterior bite. Class I with severe crowding. Class I with bimaxillary protrusion.

INDICATIONS FOR 2ND PREMOLAR EXTRACTION:

1.Good profile+mild crowding 2.flat profile+moderate crowding 3.Class II div 1 on skeletal class I + mild crowding.

4.Mild Class III inter-arch relation+mild crowding in U arch. 5.Congenitally missing, impacted. 6. Grossly destructed/heavy restoration. 7. Abnormal root morphology. 8. Open bite.

ADVANTAGES : Original facial contours retained without

reduction of lip profile. U 4 is more esthetic along side canine. Lesser tendency for extraction space to open in L arch. Less possibility of buccal/lingual furrow in extraction space. Easy correction of Class II molar correction to Class I

molar relation.

1st molar extraction

INDICATIONS : Carious- beyond restoration RC Treated, - than a perfectly good premolar. Multi filled teeth- crown. Premature Xn of 6, to preserve symmetry. Facial considerations: Large chin buttons&/ prominent nose (4- dished-in) (rationale: farther back less facial change) Open bite cases.

Wilkinsons Extraction: 1942 8 to 9 yrs. Extraction of all Ist molars. Basis: Additional space for eruption of 8s. Crowding of lower arch minimized.

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. Class II div 1 active growth over. Non-cooperative pt. Class II div 1 with good lower arch over basal bone, with some growth expectation. Class II div 1 with mild open bite

6 extraction is avoided in: Good molar relation. U 4 occlude with L4 8s erupt normally. Min patient cooperation Stable results. Tuberosity not crowded. Results similar to non-extraction. Extraction duration is reduced.

Profile maintained.

2nd MOLAR EXTRACTION:

David W.Liddle- AJO 1977

Malocclusion due to potential force by developing 7,8. Extraction of 7s to intercept this forward force. 4 extraction in treating the effect and not the cause.

10-12mm of space :Satisfies arch length problem, not apparent when patient smiles. 6 move distally in response to pressure. Over compressed conn.tissue fibers- move 3 &4 to a more normal occlusion.

ADVANTAGES AND INDICATIONS:

Disimpaction of 3rd molars, 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 residualspaces at the end of Rx Less likelihood of relapse Good functional occlusion Good mandibular arch form Overbite reduction. INDICATIONS: Chipman: Xn 7 - caries, ectopic, rotated. Mild moderate discrepancy with good profile. Crowding in tuberosity area ,with a need for distal movement of 1st molar.

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.r.t 2nd molar. No congenitally missing teeth. DISADVANTAGES: Too much tooth substance removed in Cl I mal occlusion 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.

Timing for mandibular 2nd molar extraction: Kokich:

3rd molar crowns completely formed, Xn before roots begin to develop 30*to the occlusal plane 3rd molars in close proximity to 2nd molar-drift.

Halderson, Huggins, Lehman and Smith: Before radiographic evidence of root formn.(12-14yrs) Consensus opinion: As soon as 2nd molar erupts. : Angulation.

3RD MOLAR EXTRACTION:

Xn to prevent lower anterior crowding? Distal movement of 6,7 impaction of 8.

 Xn of 8 before retracting. Contraindications: 1st or 2nd molars are extracted. Incisor Extraction:

Mandibular incisors- therapeutic value

1 sign of incipient malocclusion Difficult to treat as they relapse easily.

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Not a new idea. Jackson (1904) Riedel : Extraction of 2 lower o Incisors-arch form without expansion of o intercanine width Angle: Inexcusable. Disharmony b/w Occlusal planes, abnormal overbite
Incisor extraction: Indications For mandibular incisors: Extreme crowding / protrusion. Gingival recession & loss of overlying bone on labial surface. Lateral incisors severely # in young children. Rarely-discrepancy in sizes of U & L incisors themselves, 1 incisor can be removed. Reidel- Treatment time reduced. Minimum facial change.

INCISOR EXTRACTION:
Advantages: Maintains/ reduces intercanine width General arch form is maintained greater stability Retention period- less

 Anterior segments can be retracted readily if need be. Immediate solid tooth support of entire buccal segments. Easy reduction of overbite- intrusion, reshaping Mechanotherapy is simplified. Space closure quick.

Disadvantages : Re-opening of space : Central Incisor. Danger of creating a tooth size discrepancy. Reidel- 2 mandi incisors extracted to maintain intercanine width. 1 incisor extraction causes deepbite if normal tooth size relationship is present before Xn. Colour difference of canine.

Incisor extraction is Rarely indicated. Unfavorable impaction of U incisor. Bu/Li blocked out lateral, with good contact b/w central and canine. Congenital missing of 1 lateral incisor Dilacerated tooth.

Gardiner et al:
U crowding, mesial displacement of root apices of upper canine: Extraction of

lateral incisor.

Extraction of Canines: Not extracted: Affects profile. Long path of eruption.

 Conditions where indicated: Impossible to bring in alignment. Gross displacement Bu/Li . 4 in contact with 2 & does not show palatal cusp.

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. Efficient mechano therapy. Diagnostic line.

Larger the root surface area, greater the resistance to movement.

CONCLUSION: Orthodontic treatment may include extractions of any tooth in the arch based on sound diagnosis, treatment objectives.
REFERENCES
Contemporary Orthodontics, 4 edn; William R. Proffit Begg Orthodontic Theory and Technique, 2 edn; Current Principles and Techniques, 2 edn; T. M. Graber, Principles and Practice, 3 edn; T. M. Graber Clinical Orthodontics, vol.1 ; Charles H. Tweed Orthodontics for Dental Students, 3 edn; T. C. White, J. H. Gardiner, B. C. Leighton A text book of Orthodontics, 3 edn; T. D. Foster Second molar extraction in orthodontics, David W. Liddle; AJODO,1977
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P. R. Begg, P. C. Kesling R. L. Vanarsdall