Atypical Extractions-Oral Surgery / Orthodontic Courses by Indian Dental Academy

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www.indiandentalacademy.com
INDIAN DENTAL
ACADEMY
Leader in continuing dental education
Increased ability to move teeth under better control:
ever-expanding choice of extraction.

Factors affecting choice of extraction
1. Treatment objectives
2. Type of malocclusion
3. Esthetics (large chin button, prominent nose)
4. Growth pattern.
5. Conditions of teeth.(caries, multifilled teeth,
impacted, ectopic, severe rotation)
6. Health of supporting tissues.

Facial profile alteration:
Maxi retraction of U&L anteriors: 4s
Lesser retraction in lower face: U4s and L5s
Less overall retraction: 5s or 6s.
Deep anterior overbite:
Closer.( Mechanically easier to level, as spaces are
closed). incisors min time and effort.
Open bite:
5 or 6 Xn. Accentuate the curve of Spee.
GRABER: Removal of 5s in mandibular arch preferable.
. reduces the tendency of relapse of openbite &lingually
inclined incisors seen occasionally with Xn of 4s.
Incisors
Canines
Asymmetric premolar extraction
molars
Mandibular incisors- therapeutic importance
1
st
sign of incipient malocclusion
Difficult to treat as they relapse easily.

Not a new idea.
Jackson (1904)
Riedel(1975) : Xn of lower
Incisors

Angle:
Inexcusable. Disharmony b/w
Occlusal planes, abnormal overbite
For mandibular incisors:
Extreme crowding /
protrusion.
Gingival recession & loss of
overlying bone on labial
surface.
Lateral incisors severely # in
young children.
Discrepancy in sizes of U & L
incisors themselves, 1 incisor
can be removed.
Reidel- Rx time reduced.
min facial change.
1. Maintains/ reduces intercanine
width
2. General arch form is
maintained greater stability
3. Retention period- less
4. Anterior segments can be
retracted readily, if needed.
5. Immediate solid tooth support
of entire buccal segments.
6. Easy reduction of overbite,
reshaping
7. Mechanotherapy is simplified.
Space closure quick.
Reopening of space . Central Incisor.
Danger of creating a tooth size discrepancy.
1 incisor Xn- deepbite- if normal tooth size
relationship is present before Xn.
Color difference of canine.

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.
Trauma, caries & periodontal disease
Gardiner et al:
U crowding, mesial displacement of root apices
of U3 - Xn of lateral incisor.
Incisor Xn not often.
Possibility must always be considered.
Careful planning with diagnostic setup
Not extracted.
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.
Decision : position of apex.

Single premolar extraction
3 premolar extraction---AJO-DO sep 2003
Class II sub division
Avoided:
Not provide adequate space in the ant region.
5 & 7 may tip in the Xn space.
Deepening of bite.
Masticatory efficiency.

Carious- beyond restoration
RCTreated, - than a perfectly good premolar.
Multi filled teeth- crown.
Premature Xn of 6, to preserve symmetry.
Facial considerations: large chin buttons&/ prominent
nose
(rationale: farther back less facial change)
Open bite cases.
Indications:
Not to allow U7 locked behind L7.
Horizontal elastics until danger of locking has
passed.
Mesially inclined 7, lesser degree of anchor bend.
Wilkinsons Extraction: 1942
8 to 9 yrs. Extraction of all Ist molars.
Basis:
Additional space for eruption of 8s.
Crowding of lower arch minimized.
Disadvantages-
Class II div 1 with perfect lower arch alignment but
growth expectation inadequate.
Class II div 1 active growth over. Pt non cooperative.
Class II div 1 with good lower arch over basal bone, with
some growth expectation.
Class II div 1 with mild open bite.
Problems with Xn of 4s:
Tipping, opening of space (5 small to fill the
space)
Mesial tipping of 6, hanging palatal cusp
Avoided with 6 Xn.
Good molar relation.
U 4 occlude with L4
8s erupt normally.
Min patient cooperation
Stable results.
Tuberosity not crowded.
Results similar to nonext.
Rx duration is reduced.
Profile maintained.
Open bite correction

David W.Liddle- AJO 1977
Malocclusion: potential force by developing 7,8.
Xn of 7s to intercept this forward force.
4 Xn: treating the effect and not the cause.
10-12mm of space :satisfies arch length problem, not
apparent when patient smiles.
91% 7 Xn.
6 move distally in response to pressure.
Over compressed CT fibers- move 3 &4 to a more
normal occlusion.

ADVANTAGES AND INDICATIONS
Disimpaction of 3
rd
molars, faster eruption
Prevention of dished-in at the end of facial growth
Prevention of late incisor imbrication
Facilitation of 1
st
molar distalization
Distal movement only as needed to correct the overjet
Fewer residualspaces at the end of Rx
Good functional occlusion
Overbite reduction.
Chipman:
Xn 7 - caries, ectopic, rotated.
Mild moderate discrepancy with good profile.
Crowding in tuberosity area ,with a need for
distal movement of 1
st
molar.
Lehman - preconditions
8 in favorable angulation 15-30*angle to the long
axis of the 1
st
molar.
Normal in size/shape & root area is sufficient w.r.t
2
nd
molar.
No congenitally missing teeth.

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 3
rd
molars even with 2
nd
molar Xn
Unacceptable positions of erupted 3
rd
molars second,
late stage of fixed therapy.
9-20% missing 3
rd
molars.
Kokich:
1. 3
rd
molar crowns completely formed, Xn before
roots begin to develop
2. 30*to the occlusal plane
3. 3
rd
molars in close proximity to 2
nd
molar-drift.
Halderson, Huggins, Lehman and Smith.
Before radiographic evidence of root formn.(12-14yrs)
Consensus opinion: as soon as 2
nd
molar erupts.
angulation.
Xn to prevent lower anterior crowding?
Distal movement of 6,7 impaction of 8.
Pain
Contraindications:
1
st
or 2
nd
molars are extracted.

Relation b/w root surface area and Xn site selection upon
incisor retraction.
Efficient mechanotherapy.
Diagnostic line.
Larger the root surface area, greater the resistance to
movement.

Non extraction 1.5mm
1
st
molars u&l 6.0mm
U4 and L5
8.7mm
1
st
premolars 9.2mm
1
st
premolars
&1
st
molars
16.9mm
Location of the Xn site-
Root surface area.
Predict incisor retraction.
Should be considered in diagnosis, so that a desired Rx
goal for the final position of incisors within the facial
profile can be achieved.

Orthodontic treatment may include extractions of
any tooth in the arch.
Based on sound diagnosis, treatment objectives.
Different extractions for different malocclusions Sidney
Brandt, Safirstein AJO 1975
Extractions in Orthodontics- Nagalakshmi & Ashima
Valiathan JICD vol 37 1995
Single arch extraction- upper first molars or what to do when
nonextraction treatment fails- Raleigh Williams AJO oct
1979
Second molar extractions: A review Samir Bishara, AJO-
DO 1986 may
Second molar extraction in orthodontic treatment- David W.
Liddle AJO dec 1977
Third Molars: A review Samir E. Bishara AJO feb 1983

The effect of different extraction sites upon incisor retraction-
Raleigh Williams & Hosila AJO 1976
Where teeth should be positioned in the face and jaws and how
to get them there---Thomas Creekmore JCO sep 1997
Class II subdivision treatment success rate with symmetric and
asymmetric extraction protocols- Guilherme Jansson, Dainesi,
Fernando. AJO-DO sep 2003
Thank you
Leader in continuing dental education

Atypical Extractions-Oral Surgery / Orthodontic Courses by Indian Dental Academy

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