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Serial extraction


The term serial extraction describes an orthodontic treatment procedure that involves the orderly removal of selected deciduous and permanent teeth in a predetermined sequence …

The term serial extraction describes an orthodontic treatment procedure that involves the orderly removal of selected deciduous and permanent teeth in a predetermined sequence

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  • 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
  • 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,


  • 1. 1
  • 2.  Introduction  Definitions  Historical development  Rationale  Indications  Contraindications  Advantages  Disadvantages  Diagnostic procedures  Techniques  Conclusion  References 2
  • 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
  • 15. 15
  • 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
  • 29.  Tooth size jaw size discrepancy  Absence of physiologic spacing 29
  • 30.  Lingual eruption of permanent lateral incisor 30
  • 31.  Unilateral deciduous canine loss and shift to the same side 31
  • 32.  Mal positioned or impacted lateral incisors that erupt palatally out of the arch 32
  • 33.  Abnormal / asymmetric primary canine root resorption 33
  • 34.  Labial stripping, or gingival recession, usually of lower incisor. 34
  • 35.  Mesial eruption of canines over lateral incisors.  Mesial drift of buccal segment  Abnormal eruption direction and eruption sequence 35
  • 36.  Deleterious oral habits Flaring,  ectopic eruption  Ankylosis etc. 36
  • 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
  • 41.  Requires clinical judgment  Prolonged treatment time( 2-3 years)  Patient compliance( multiple visits)  Psychological trauma of extraction. 41
  • 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
  • 52. 52
  • 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
  • 55.  Complete series of periapical radiographs or a panoramic radiograph. 55
  • 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
  • 60.  Essential analysis include: 1. Arch lenth 2. Space available and 3. Profile 4. Total space analysis 60
  • 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
  • 69. 69
  • 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
  • 75. 75
  • 76. 76
  • 77. 77
  • 78. 78
  • 79. 79
  • 80. 80
  • 81. 81
  • 82. 82
  • 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
  • 84. 84
  • 85. 85
  • 86. 86
  • 87. 87
  • 88. 88
  • 89. 89
  • 90. 90
  • 91. 91
  • 92. 92
  • 93. 93
  • 94. 94
  • 95. 95
  • 96. 96
  • 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
  • 102.  A-N-B angle: 2 to 5˚ 102
  • 103.  Mandibular plane angle( S-N-Go-Gn) :30-36 ˚ 103
  • 104.  Incisor mandibular plane angle( IMPA): 93-100 ˚ 104
  • 105.  Mandibular incisors in front of A-Pog line 105
  • 106.  Maxillary incisors to S-N line: 110-115˚ 106
  • 107. 107
  • 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
  • 111.  Extract  Then, primary molars and enucleation of first premolar at the same time 111
  • 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
  • 114.  Overbite will increase after a serial extraction.  So not indicated. 114
  • 115.  It should be planned according to its severity and type.  If not it will worsen the problem. 115
  • 116.  Normal overjet  Minimal overjet  Severe overjet 116
  • 117.  If no mandibular crowding present,  Then management is by eliminating maxillary crowding 117
  • 118.  Extract maxillary primary canine  Then extract primary first molar  Later maxillary first premolar is extracted. 118
  • 119.  canine  Molar interdigitation- Class I second molar interdigitation: class II 119
  • 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
  • 121.  This requires concurrent orthopedic appliance along with serial extraction. 121
  • 122.  Skeletal class III malocclusion - Poor candidates 122
  • 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
  • 124.  Root paralleling  Inadequate  Spaces buccal digitations remaining unclosed  Excessive  Skeletal overbite & overjet and profile disharmony  Anchorage consideration 124
  • 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