BDS [Orthodontics] course

1. EXTRACTIONS IN ORTHODONTICS
PROF (Dr.) SAIBEL FARISHTA

2. TO EXTRACT OR NOT TO EXTRACT HAS ALWAYS BEEN AND WILLALWAYS
REMAIN A CONTROVERSY IN ORTHODONTICS. THE GREAT EXTRACTION
CONTROVERSY OF 1920’S WAS BASED ON TWO SCHOOLS OF THOUGHTS.
E H ANGLE, WHO CHAMPIONED NON-EXTRACTION TREATMENT LINE, AND
CALVIN CASE, WHO ADVOCATED EXTRACTIONS.
ANGLE BELIEVED THAT ANY PERSON WAS CAPABLE OF HAVING 32 TEETH
IN NORMAL OCCLUSION AND EVERY PATIENT REQUIRED EXPANSION OF
ARCHES.
CALVIN CASE BELIEVED THAT ALTHOUGH THE ARCHES COULD ALWAYS BE
EXPANDED, NEITHER ESTHETICS NOR STABILITY WOULD BE
SATISFACTORY IN THE LONG TERM FOR MANY PATIENTS, THUS REQUIRED
EXTRACTIONS.
IN LATE 1940’S, EXTRACTION WAS REINTRODUCED BY CHARLES TWEED,
WHO OBSERVED THAT POST TREATMENT OCCLUSION WAS MORE STABLE
IN PATIENTS TREATED WITH EXTRACTION OF FOUR PREMOLARS.
HISTORICAL BACKGROUND

3. 1. ARCH LENGTH – TOOTH MATERIAL DISCREPANCY
2. CORRECTION OF SAGITTAL INTERARCH RELATIONSHIP
• ANGLE’S CLASS I
• ANGLE’S CLASS II
• ANGLE’S CLASS III
3. ABNORMAL SIZE AND FORM OF TEETH
MACRODONTIA, HYPOPLASTIC TEETH, DILACERATION, ABNORMAL
CROWN MORPHOLOGY
4. SKELETAL JAW MALRELATIONS
SURGICAL PROCEDURES ALONG WITH EXTRACTIONS
THE NEED FOR EXTRACTION

4. THE CHOICE OF TEETH FOR EXTRACTION
1. UPPER INCISORS
2. LOWER INCISORS
3. CANINES
4. FIRST PREMOLARS
5. SECOND PREMOLARS
6. FIRST MOLARS
7. SECOND MOLARS
8. THIRD MOLARS

5. 1. EXTRACTION OF UPPER INCISORS
ALTHOUGH, THE UPPER INCISORS ARE RARELY EXTRACTED,
EXTRACTION IS INDICATED WHEN –
• UNFAVOURABLY IMPACTED UPPER INCISOR IS PRESENT, WHICH
CANNOT BE ALIGNED
• IF THE LATERAL INCISOR IS BUCCALLY OR PALATALLY LOCKED AND
GOOD CONTACT IS PRESENT BETWEEN CENTRAL INCISOR AND
CANINE
• IF ONE LATERAL IS CONGENITALLY MISSING, THE OPPOSITE SIDE
LATERAL MAY BE EXTRACTED TO MAINTAIN ARCH SYMMETRY
• BADLY CARIOUS INCISOR, WHICH CANNOT BE RESTORED
• MALFORMED INCISOR CROWNS, THAT CANNOT BE RESTORED BY
PROSTHESIS
• TRAUMA/DAMAGE TO INCISORS WHICH CANNOT BE RESTORED
• INCISORS HAVING DILACERATED ROOT, WHICH ARE DIFFICULT TO
MOVE ORTHODONTICALLY

6. 2. EXTRACTION OF LOWER INCISORS -
LOWER INCISOR EXTRACTIONS MAY LEAD TO NARROWING OF
LOWER INTER CANINE WIDTH, RETROCLINATION OF LOWER
INCISORS, DEEP BITE AND REAPPEARENCE OF CROWDING,
LEADING TO COLLAPSE OF THE ARCH.
• IF ONE INCISOR IS OUT OF THE ARCH AND THE REST OF THE TEETH
ARE IN GOOD INTER DENTAL CONTACT
• LOWER INCISOR HAVING SEVERE CARIES, GINGIVAL RECESSION OR
BONE LOSS HAVING POOR PROGNOSIS
• IN MILD CLASS III CASES WITH LOWER INCISOR CROWDING, SO AS
TO RELIEVE THE CROWDING.
CONDITIONS WHEN THEY CAN BE EXTRACTED -

7. 3. EXTRACTION OF CANINES -
EXTRACTION OF CANINES MAY LEAD TO FLATTENING OF THE
FACE, ALTERED FACIAL BALANCE, CHANGE IN FACIAL
EXPRESSION, IMPROPER OCCLUSION.
CANINES MAY BE EXTRACTED WHEN -
• UNFAVOURABLY PLACED IMPACTED CANINES
• WHEN THE CANINE IS COMPLETELY OUT OF THE ARCH WITH GOOD
CONTACT BETWEEN LATERAL AND PREMOLAR
• PREMATURE SHEDDING OF A DECIDUOUS CANINE USUALLY
INDICATES THE EXTRACTION OF OTHER SIDE CANINE
• IN CLASS II CASES, IF THE LOWER DECIDUOUS CANINE IS SHED
EARLY, THE UPPER DECIDUOUS CANINE ALSO SHOULD BE REMOVED
TO AVOID WORSENING OF CLASS II
• IN CLASS III CASES, IF THE UPPER DECIDUOUS CANINE IS SHED
EARLY, THE LOWER DECIDUOUS CANINE ALSO SHOULD BE
REMOVED TO AVOID WORSENING OF CLASS III
• DECIDUOUS CANINE MAY BE EXTRACTED AS A PART OF SERIAL
EXTRACTION PROCEDURE

8. 4. EXTRACTION OF FIRST PREMOLARS -
THEY ARE THE MOST COMMONLY EXTRACTED TEETH. THE
REASON FOR THEIR EXTRACTION IS AS FOLLOWS -
• THEIR LOCATION IN THE ARCH IS SUCH THAT THE SPACE GAINED
AFTER IT’S EXTRACTION CAN BE UTILIZED FOR CORRECTION BOTH
IN THE ANTERIOR AND POSTERIOR SEGMENTS
• GOOD CONTACT RESULTS BETWEEN THE CANINE AND SECOND
PREMOLARS
• THE EXTRACTION OF FIRST PREMOLAR LEAVES BEHIND A
POSTERIOR SEGMENT THAT OFFERS ADEQUATE ANCHORAGE FOR
THE RETRACTION OF SIX ANTERIOR TEETH IF REQUIRED.
INDICATIONS FOR FIRST PREMOLAR EXTRACTION -
• THEY ARE THE TEETH OF CHOICE FOR EXTRACTION TO RELIEVE
MODERATE TO SEVERE ANTERIOR CROWDING OF UPPER /LOWER
ARCHES
• IN CLASS II DIV 1 AND BIMAXILLARY PROTRUSION CASES.

9. 5. EXTRACTION OF SECOND PREMOLARS -
INDICATIONS FOR SECOND PREMOLAR EXTRACTION -
• SECOND PREMOLAR EXTRACTION RESULTS IN STRENGTHENING OF
ANTERIOR ANCHORAGE SEGMENT. THE SECOND PREMOLARS ARE
EXTRACTED IN MILD ANTERIOR CROWDING CASES
• WHEN 4-5 MM OF ANCHOR LOSS IS DELIBERATELY REQUIRED
• UNFAVOURABLY IMPACTED SECOND PREMOLARS
• IN OPEN BITE CASES, AS THEIR EXTRACTION ENCOURAGES
DEEPENING OF THE BITE
• GROSSLY CARIOUS OR DEEPLY FILLED SECOND PREMOLAR HAS TO
BE EXTRACTED
• A SECOND PREMOLAR OUT OF THE ARCH DUE TO MESIAL
MOVEMENT OF FIRST MOLAR

10. 6. EXTRACTION OF FIRST PERMANENT MOLARS -
EXTRACTION OF THE FIRST PERMANENT MOLARS IS AVOIDED
BECAUSE -
• THE EXTRACTION OF THE FIRST MOLAR DOESN’T GIVE ADEQUATE
SPACE IN THE INCISOR REGION
• IT RESULTS IN DEEPENING OF THE BITE
• THE SECOND PREMOLARS AND MOLARS MAY TIP INTO THE
EXTRACTION SPACE
• MASTICATION MAY BE DIFFICULT
INDICATIONS FOR FIRST MOLAR EXTRACTION -
• WHEN THERE IS MINIMAL SPACE REQUIREMENT FOR CORRECTION
OF MILD ANTERIOR CROWDING OR PROCLINATION
• BADLY DECAYED OR HEAVILY FILLED MOLAR
• OPEN BITE CASES CAN BENEFIT, AS THERE WILL BE DEEPENING OF
BITE AFTER EXTRACTION

11. WILKINSON’S EXTRACTION -
WILKINSON’S ADVOCATED EXTRACTION OF ALL FOUR
PERMANENT MOLARS BETWEEN THE AGE OF 8.5 TO 9.5 YEARS AS
HE BELIEVED THAT THEY ARE MOST SUSCEPTIBLE TO CARIES.
THE OTHER BENEFITS OF EXTRACTING FIRST MOLARS AT AN
EARLY AGE IS -
• THEIR EXTRACTION PROVIDES ADDITIONAL SPACE FOR ERUPTION
OF THIRD MOLARS, THUS THIRD MOLAR IMPACTION CAN BE
AVOIDED
• CROWDING OF THE ARCH IS MINIMIZED
DRAWBACKS OF WILKINSON’S EXTRACTION
• THE EXTRACTION OF FIRST MOLARS OFFERS LIMITED SPACE TO
RELIEVE CROWDING
• THE SECOND PREMOLARS AND SECOND MOLARS MAY ROTATE AND
TIP INTO THE EXTRACTION SPACE
• THE REMOVAL OF THE FIRST MOLARS LEAVES LESS ANCHORAGE
FOR ORTHODONTIC APPLIANCE.

12. 7. EXTRACTION OF SECOND PERMANENT MOLARS -
INDICATIONS -
• TO PREVENT THIRD MOLAR IMPACTION
• TO RELIEVE IMPACTION OF SECOND PREMOLARS
• TO RELIEVE LOWER INCISOR CROWDING
• TO ENABLE DISTALIZATION OF FIRST MOLARS
• IN OPEN BITE CASES
8. EXTRACTION OF THIRD MOLARS -
• GROSSLY IMPACTED THIRD MOLARS WHICH ARE UNABLE TO ERUPT
INTO IDEAL POSITION, ARE REMOVED
• TO RELIEVE LATE LOWER ANTERIOR CROWDING
• MALFORMED THIRD MOLARS THAT INTERFERE WITH NORMAL
OCCLUSION ARE ALSO EXTRACTED

13. BALANCING EXTRACTIONS
BALANCING EXTRACTIONS REFERS TO REMOVAL OF ANOTHER
TOOTH ON THE OPPOSITE SIDE OF THE SAME ARCH, TO PREVENT
DENTAL MIDLINE SHIFT.
COMPENSATING EXTRACTIONS
THIS REFERS TO EXTRACTION OF TEETH IN OPPOSITE JAWS TO
PRESERVE THE BUCCAL OCCLUSAL RELATIONSHIP.

14. THANK YOU