The term serial extraction describes an orthodontic treatment procedure that involves the orderly removal of selected deciduous and permanent teeth in a predetermined sequence
3. Dewel
1969
Serial extraction can be defined as
“the correctly timed, planned removal of certain
deciduous and permanent teeth in mixed
dentition cases with dento-alveolar disproportion
in order to:
3
4.
Alleviate crowding of incisor teeth.
Allow unerupted teeth to guide themselves into
improved positions (canines in particular).
Lessen (or eliminate) the period of active
appliance therapy.
4
5.
“It is a sequential plan of premature removal of
one or more deciduous teeth in order to improve
alignment of succedaneous permanent teeth and
finally removal of permanent teeth to maintain
the proper ratio between tooth size and available
bone”.
5
6.
an interceptive orthodontic procedure to intercept
and reduce dental crowding
carried out during mixed dentition period
Involves planned and sequential removal of
primary and permanent teeth
6
7. Proffit
- Timed extraction of primary and,
ultimately, permanent teeth to relieve
severe crowding.
7
8. “An
orthodontic treatment procedure that
involves the orderly removal of selected
deciduous and permanent teeth in a
predetermined sequence”
8
9. Early
recognition or anticipation of a deformity
that will occur unless teeth are removed at
strategic intervals to relieve in intensity the
developing malocclusion.
9
10. Defined
as correctly timed, planned removal
of certain deciduous and permanent teeth in
mixed dentition cases with dento- alveolar
disproportion .
10
11.
Balance enforced extractions
Extraction of a tooth from the
opposite
side of the same arch, designed to minimize
centre line shift.
Compensate enforced extractions
Extraction of a tooth from the
quadrant
opposing
to the enforced extraction
11
12. Arch
perimeter ( circumference)
-The distance from the mesial contact of one
first permanent molar to its antimere as measured
through the contact points or buccal cusp tips of all
of the intervening teeth.
12
13.
Arch length( depth)
- the perpendicular distance from
a point between the central
incisors to a line connecting the
mesial contacts of the first
permanent molars
13
14. Arch width:
Inter- canine width: perpendicular distance cusp tip
of one canine to that of opposite canine.
Inter-molar width: perpendicular distance from
mesial pit of one molar to that of opposite molar.
14
16. Paisson
was the first person
who pointed the extraction
procedure in order to improve
the irregular alignment and
crowding of teeth.
16
17.
The names that stand out particularly for the modern
development of the serial extraction concept are
Kjellgren of Sweden
Hotz of Switzerland,
Heath of Australia and
Nance, Hoyd, Dowel and Mayne of the United States.
17
18.
Nance presented clinics on his technique of
“progressive extraction” in 1940 and has been
called as the father of “serial extraction”
philosophy in the United States.
Kjellgren in 1940 termed this extraction
procedure as “planned” or “progressive”
extraction procedure of teeth.
18
19.
Hotz named the same procedure on “Guidance of
eruption”.
According to him the term guidance of eruption is
comprehensive and encompasses all measures
available for influencing tooth eruption.
19
20.
Widespread adoption of serial extraction :
source of concern to all Pedodontists
its limitations as well as of its possibilities.
The principle reason is that its application involves
growth prediction.
20
21.
Every serial extraction diagnosis is based on the
promise that future growth will be inadequate to
accommodate all of the teeth in a normal
alignment.
21
22. Has
it foundations based on facts and
processes:
1. Tooth material-arch length deficiency
2. Physiologic tooth movement
3. Normal dental, skletal and profile
development
22
23.
Predicting at an early stage, the lack of space in future
permanent dentition to accommodate all teeth
Objective is to intercept arch length discrepancy
to reduce or eliminate the need of extensive appliance
therapy.
23
24. Serial extraction is based on two basic principles
ARCH
LENGTH – TOOTH MATERIAL DISCREPANCY
PHYSIOLOGIC
TOOTH MOVEMENT
24
25.
As Nance (1940), Mooress (1963), Dewel (1954),
and others have pointed out,
After the eruption of the first permanent molars
at 6 years of age
25
26.
If there is any change, it may be an actual
reduction of the molar-to-molar arch length,
26
27.
The following is a list of possible, clinical clues
for serial extraction, occurring singly or in
combination:
27
28. Severe
crowding with arch deficiency of 8-10
mm or more
In
class I malocclusion with no skeletal
disproportions and showing harmony between
skeletal and muscular system with normal
overbite & good skeletal profile.
28
37.
Congenital absence of teeth providing space
Mild to moderate crowding
Deep or open bites
Severe Class II, III of dental/Skeletal origin
Cleft lip and palate
Spaced dentition
37
38.
Anodontia / oligodontia,
Midline diastemia
Dilacerations
Extensive caries
Disportion between arc length and tooth material
which can be treated by serial extraction.
38
39.
Psychological trauma can be avoided by treatment
Reduces the duration of the multi banded
treatment
Physiologically treatment
(as it involves the guidance of teeth into normal positions
making use of physiological forces)
Better oral hygiene
39
40. Reduces
More
cost of treatment
stable results
Lesser
retention period is required.
40
42.
Possibility of developing tongue thrust
Arch length reduction
Ditching between canine and second premolar
Axial inclination should be corrected later.
42
43. Reversible phase
Irreversible phase
Done during
first transitory
period
second transitory
period
Extraction of
anterior
deciduous teeth
extraction of
permanent teeth
allow the alignment of
the permanent incisors,
correcting the crowding
of the posterior
segment
43
44. 1.
Proportional facial analysis :
According to Graber (1971), the face is
divided into,
Standard or orthognathic face i.e. the
relationship between
maxilla and mandible,
Are
Normal
maxilla and maxillary dentition
mandible and mandibular dentition and
maxillary dentition and mandibular dentition
44
45. 2) Alveodental protrusion:
Class I maxillary mandibular alveodental protrusion:
The facial pattern is normal, dentition arc, relatively
forward.
This facial pattern responds well to Serial Extraction.
Class II maxillary alveodental protrusion:
The maxillary dentition is forward can be treated with
Serial Extraction in maxilla only.
Class III: Not suitable for Serial Extraction.
45
46. 3) Alveodental retrusion:
Class I maxillary mandibular alveodental retrusion :
patients should be treated without extractions.
extractions create a dished in face.
Class II: Mandibular alveodental retrusion :
Serial Extraction not indicated.
46
47. 4) Prognathism:
Class I Maxillary mandibular prognathism –
Indicated if,
teeth are severely crowded.
Because of the increase in size of jaws, extraction
usually not indicated.
47
48.
Class II Maxillary prognathism :
fault in the maxillary base itself /
long anterior cranial base/
the cranial base being flat
(creating a downward and forward position of the
nasomaxillary complex)
Difficult to treat with Serial Extraction.
48
49. Retrognathism :
Class I maxillary mandibular retrognathism :
As the maxilla and mandible are replaced
relatively backwards, extractions are
contraindicated.
49
50.
Class II mandibular retrognathism :
small corpus of mandible or small ramus or due
to excess vertical development of nasomaxillary
complex.
In such cases, the mandible rotates backwards
and creates an open bite.
Not a good case for Serial Extraction
50
51. I. EXAMINATION AND CONSULTATION
II. DIAGNOSTIC RECORDS
o
Photographs
o
Radiographs
o
Study models
o
Essential analysis
51
53. Evaluation
of craniofacial and dental
relationship and proportions before treatment
Assessment
of soft tissue profile
Proportional
facial analysis
53
54.
Monitoring of treatment progress
Detecting and recording muscle imbalance and
balance
Detecting and recording facial asymmetry
Identifying patients
54
56. Must be taken for ---
Calculation of the total space analysis
Detection of supernumerary teeth
Evaluation of the dental health of the permanent
teeth, especially the first molars
Detection of pathologic conditions in the early
stages
56
57.
Detection of evidence of a tooths size jaw size
discrepancy such as the resorptive pattern on the
mesial of the roots of the primary canines
Determination of the size, shape and relative
position of the unerupted permanent teeth
Evaluation of the eruptive patterns of unerupted
permanent teeth
57
58.
Dental stage of the patient by assessing the length
of the roots of permanent unerupted teeth
Root resorption before during and after treatment
Final appraisal of the dental health after
orthodontic treatment
58
59.
Evaluation of craniofacio - dental relationships
before treatment
Assessment of the soft tissue matrix
Classification of facial pattern.
59
61.
Arch length analysis:
Determines the amt of spacing / crowding and
where it exists in dental arches.
Dental development analysis:
When teeth are likely to erupt
Profile evaluation:
Facial pattern
61
62.
Assess and record
the dental anatomy
the intercuspation
arch form
the curves of occlusion
62
63.
Evaluate occlusion with the aid of articulators
Measure progress during treatment
Detect abnormalities (eg. localized enlargement,
distortion of arch form)
63
64.
Calculation of tooth size jaw size discrepancies.
Determination of mandibular rest position.
Prediction of growth and development
64
65. Profile
: convex
Lips
: anterior to line drawn from
nose to chin
Overjet
: < 5mm
Overbite
: < 30mm
NO
of teeth,
size & shape
Developmental
: normal
pattern : symmetric.
65
66.
3 areas: anterior, middle & posterior and resulting
values for each area were added together to yield
final deficit.
Anterior area:
Calculation is done btw space required and space
available
Sp available: Includes Tooth measurement and Ceph
correction+ soft tissue modfn.
66
67.
Tooth analysis
Measurement of mandibular incisors on cast were
added to the values obtained from the
radiographic measurement of canines.
Ceph’ correction: Calcltd acc to tweed’s method.
67
68.
Instead of measurements being made of the dist on
the occlusal plane, btw the objective line and the
line indicating the true axial inclination of the
mandibular incisors,
The actual FMIA was subtracted(in degrees) from
the proposed angle and the difference was
multiplied by a constant(0.8) , to give the
difference in millimeters.
68
70. Soft tissue modf’n:
Thus teeth jaws, and soft tissue are all involved in
assessment.
It is done by measuring the Z angle of Merifield and
adding ceph’ corr’ to it.
70
71. If the correctd, Z angle was grtr than 8o*,
then mandibular incisor inclination was
modified as
necessary(upto an IMPA of approx 92*)
If the corrected angle was less than 75*,
add’nl uprighting of the mandibular incisors
was necessary.
71
72.
Upper lip thickness was measured from the
vermillion border of the lip to the greatest
curvature of the labial surface of the central
incisor.
Total chin thickness was measured from the soft
tissue chin to the N-B line.
72
73. If lip thickness was greater than chin
thickness
the diff was determined and multiplied by 2
and added to space req’d
If it was less or equal to chin thickness, no soft
tissue modificationn was necessary
73
74.
There is no definite “recipe” for this
procedure- Rudolf Holtz
74
83. If canine is erupting faster
than premolar
then enucleation of first
premolar can be done.
Or extraction of 2nd
deciduous molar followed by
lingual arch space maintainer
83
97. 8-9 YRS
C extracted
After 1 year
D are extracted
Eruption of 4 is accelerated
Erupting 4 is extracted
Canines erupt in alignment
97
98. 8 YRS
All D are extracted
C are maintained to retard the erupt’n
of perm’ Canines
After 4 -10 months
Extract all four erupting 4 along with
four C
Canines and incisors are aligned
98
99. Extraction of all D
Extraction of all 4’s
Extraction of all C’s
Canines erupt in
alignment
99
100. Premature loss of mandibular primary canine.
Usually accompanied by midline shift if
skeletal, dental , and profile patterns
overjet, overbite, axial inclinations,
normal
and number, size , shape,
developmental pattern
5-10mm or more arch length discrepancy
100
101. Remaining
If
primary canine should be extracted.
1st premolar root is formed more than half,
primary 1st molar extracted.
Then,
1st premolar extracted as they emerge.
Extraction
should be symmetrical.
101
108. If 5 mm
discrepancy
per
quadrant.
( Dewel’s
method)Firs
t extract
primary
canines
When, first
premolar
roots are
formed more
than half,
extract 1st
deciduous
MOLAR
Then
extract 1st
premolar
as they
erupt.
108
109. Discrepancy of
6-10mm
Seen where
crowding is
more in canine
premolar
region
Or with bimaxillary
protrusion
Objective
should be to
eliminate the
first premolars
as soon as
possible.
109
110. •Extract primary first molar
1
2
•Allow 1st premolar to erupt before
canine
• Extract 1st premolar & primary
canine
110
112. In
this situation,
Enucleation
of second premolar rather than first
premolar should be considered.
112
113.
Depends on type and severity of open bite
If open bite is dental, sequence will be similar
to others.
If skeletal, most posterior teeth in dental arch
should be extracted.
Includes extracting of enucleating permanent
molars or second premolar.
113
120.
If crowding present in both maxillary &
mandibular arches Extract maxillary primary 1st molar
& Mandibular primary 2nd molar
Then, enucleation of permanent
mandibular 2nd molar.
Then, when maxillary 1st premolar erupt,
it is extracted along with maxillary
primary canine.
120
123.
With anterior cross bite and functional slide.
E.g. primary mandibular canine in cross bite with
maxillary lateral incisor it can be extracted.
Once cross bite is corrected serial extraction is
stopped.
123
125. The
most frequently used orthodontic
appliance with serial extraction are:
Maxillary
Fixed
and mandibular lingual arches.
or removable headgears.
Removable
Hawley appliance.
125
126.
Effect of serial extraction alone on crowding:
relationships between tooth width, arch length,
and crowding.
Maxillary dental casts from 32 subjects who had
undergone only serial extraction were analyzed at 3
stages: before deciduous canines extraction, after
first premolars extraction, and at the end of the
observation period.
126
127.
These results suggest that tooth width and arch length
discrepancy might preferentially affect the degree of
anterior crowding in cases of severe crowding.
There was no aggravation of the average crowding level
during the observation period in the present study.
The present study quantitatively suggested that serial
extraction was useful for the purpose of correcting
crowding in most cases.
127
128.
Serial extraction of first premolars-postretention
evaluation of stability and relapse.
Cases evaluated: 30 patients who had undergone serial
extraction of deciduous teeth plus first premolars
followed by comprehensive orthodontic treatment and
retention.
Diagnostic records were available for the following
stages: pre-extraction, start of active treatment, end
of active treatment, and a minimum of 10 years postretention.
128
129.
All cases were treated with standard edgewise
mechanics and were judged clinically satisfactory
by the end of active treatment.
Twenty-two of the 30 cases (73%) demonstrated
clinically unsatisfactory mandibular anterior
alignment postretention.
129
130.
Intercanine width and arch length decreased in 29
of the 30 cases by the post-retention stage.
There was no difference between the serial
extraction sample and a matched sample
extracted and treated after full eruption.
130
131.
This reports a case treated by a serial extraction
program at the mixed dentition stage followed
by a corrective orthodontic treatment, with a
long-term follow-up period.
131
132.
20 yrs after the interceptive treatment, a
harmonious face was observed along with
treatment stability in the anterior posterior
direction, deep overbite(which has been
mentioned as a disadvantage of the serial
extraction program), and a small relapse of
anterior tooth crowding.
132
133.
These conditions : normal occurrences for most
orthodontic treatments with a long-term follow-up
period.
THUS, establishment of a serial extraction
protocol determined relevant esthetic changes
that afforded an improvement of the patient's
self-esteem, with a positive social impact.
133
134.
Furthermore, the low cost ,permits the use of
this therapy with underprivileged populations.
It is important to emphasize that an early
correction of tooth crowding by this protocol
does not guarantee stability, but small relapses
do not invalidate its accomplishment.
134
135.
Has its both advantages and disadvantages.
Diagnostic skill, knowledge and experience are
critical.
“ SERIAL EXTRACTION IS NOT PANACEA FOR ALL
CROWDED ARCHES”
135
Editor's Notes
The term serial extraction describes an orthodontic treatment procedure that involves the orderly removal of selected deciduous and permanent teeth in a predetermined sequence
Acc to Moore(1959), there is minimal increse in mandibular intercanine width btw 8-18 yrs of age, usually during eruption of perm’ canines, whereas max’ increases slightly more & over a longer time.DENTAL ARCH PERIMETER: iefrm distal of mand’ pri’ 2nd molar to its antimere is less in permanent than pri
Serial extraction is not new. It has been of interest to dentist for many years. Throughout the history of dentistry it has been recognized that the removal of one or more irregular teeth would improve the appearance of the reminder.
Bunon in 1743, in his “Essay on the Diseases of the teeth” proposed the removal of deciduous teeth to achieve a better alignment of permanent teeth.The interest on serial extraction increased following World War II.
Widespread adoption of serial extraction as a corrective treatment procedure continues to be a source of concern to all Pedodontists who are aware
there is probably no increase in the distance from the mesial aspect of the first molar on one side around the arch to the mesial aspect of the first molar on the opposite side.
as the "leeway" space is lost through the mesial migration of the first permanent molars during the tooth-exchange process and correction of the flush terminal plane relationship.
preferably without orthodontic mechanics. The second phase may or may not be performed
Such patients should be treated without extractions.Because extractions create a dished in face.
May be due to
May be due to
Intra oral and extra oral photographs need to be obtd.
Cephalometric and panoramic
DeterminationdETECTION
Divided into 3 areas
the actual FMIA was subtracted(in degrees) from the proposed angle and the difference was multiplied by a constant(0.8) , to give the difference in millimeters.58: Z angle of merfield + cephcorr”Crown width of mand’ first molar measured at greatestMD diam. These were added to premolar mesurements on radiographsFlat object was placed on occlusal surface of mand teeth contacting mandibular 1st molars and incisors. Deepst point on this fla surface measued.Curve of occlusion: A curved surface that makes simultaneous contact with themajor portion of the incisal and occlusal prominences of the existing teethRight side depth + Left side depth/2Post: Consists of MD width of 2nd and 3rd molars which are unerupted, also calc radiographic enlargementEstimated increase: 3mm(1.5 each side) upto 14 yrs of age.
There is no one plan applicable to all situations. Every serial extraction must be individualized to accomplish the objectives for the particular patients developing malocclusion.
provides space for alignment of incisors
when first premolar root formation is completed more than ½
ENUCLEATION CAN DAMAGE CORTICA PLATES
Deciduous canines are maintained
If all four premolars extracted n space lost due to failed serial extraction, difficult to manage by appliance therapy.
All these conditions have been regarded as normal occurrences
both advantages and disadvantages.diagnostic skill, knowledge, experience,