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
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,
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:
Alleviate crowding of incisor teeth.
Allow unerupted teeth to guide themselves into
improved positions (canines in particular).
Lessen (or eliminate) the period of active
“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
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
- Timed extraction of primary and,
ultimately, permanent teeth to relieve
orthodontic treatment procedure that
involves the orderly removal of selected
deciduous and permanent teeth in a
recognition or anticipation of a deformity
that will occur unless teeth are removed at
strategic intervals to relieve in intensity the
as correctly timed, planned removal
of certain deciduous and permanent teeth in
mixed dentition cases with dento- alveolar
Balance enforced extractions
Extraction of a tooth from the
side of the same arch, designed to minimize
centre line shift.
Compensate enforced extractions
Extraction of a tooth from the
to the enforced extraction
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.
Arch length( depth)
- the perpendicular distance from
a point between the central
incisors to a line connecting the
mesial contacts of the first
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.
was the first person
who pointed the extraction
procedure in order to improve
the irregular alignment and
crowding of teeth.
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.
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.
Hotz named the same procedure on “Guidance of
According to him the term guidance of eruption is
comprehensive and encompasses all measures
available for influencing tooth eruption.
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
Every serial extraction diagnosis is based on the
promise that future growth will be inadequate to
accommodate all of the teeth in a normal
it foundations based on facts and
1. Tooth material-arch length deficiency
2. Physiologic tooth movement
3. Normal dental, skletal and profile
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
Serial extraction is based on two basic principles
LENGTH – TOOTH MATERIAL DISCREPANCY
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
If there is any change, it may be an actual
reduction of the molar-to-molar arch length,
The following is a list of possible, clinical clues
for serial extraction, occurring singly or in
crowding with arch deficiency of 8-10
mm or more
class I malocclusion with no skeletal
disproportions and showing harmony between
skeletal and muscular system with normal
overbite & good skeletal profile.
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
Anodontia / oligodontia,
Disportion between arc length and tooth material
which can be treated by serial extraction.
Psychological trauma can be avoided by treatment
Reduces the duration of the multi banded
(as it involves the guidance of teeth into normal positions
making use of physiological forces)
Better oral hygiene
cost of treatment
retention period is required.
Possibility of developing tongue thrust
Arch length reduction
Ditching between canine and second premolar
Axial inclination should be corrected later.
allow the alignment of
the permanent incisors,
correcting the crowding
of the posterior
Proportional facial analysis :
According to Graber (1971), the face is
Standard or orthognathic face i.e. the
maxilla and mandible,
maxilla and maxillary dentition
mandible and mandibular dentition and
maxillary dentition and mandibular dentition
2) Alveodental protrusion:
Class I maxillary mandibular alveodental protrusion:
The facial pattern is normal, dentition arc, relatively
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.
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.
Class I Maxillary mandibular prognathism –
teeth are severely crowded.
Because of the increase in size of jaws, extraction
usually not indicated.
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
Difficult to treat with Serial Extraction.
Class I maxillary mandibular retrognathism :
As the maxilla and mandible are replaced
relatively backwards, extractions are
Class II mandibular retrognathism :
small corpus of mandible or small ramus or due
to excess vertical development of nasomaxillary
In such cases, the mandible rotates backwards
and creates an open bite.
Not a good case for Serial Extraction
I. EXAMINATION AND CONSULTATION
II. DIAGNOSTIC RECORDS
of craniofacial and dental
relationship and proportions before treatment
of soft tissue profile
Monitoring of treatment progress
Detecting and recording muscle imbalance and
Detecting and recording facial asymmetry
Complete series of periapical radiographs or a
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
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
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
Evaluation of craniofacio - dental relationships
Assessment of the soft tissue matrix
Classification of facial pattern.
Essential analysis include:
Space available and
Total space analysis
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
Assess and record
the dental anatomy
the curves of occlusion
Evaluate occlusion with the aid of articulators
Measure progress during treatment
Detect abnormalities (eg. localized enlargement,
distortion of arch form)
Calculation of tooth size jaw size discrepancies.
Determination of mandibular rest position.
Prediction of growth and development
: anterior to line drawn from
nose to chin
: < 5mm
: < 30mm
size & shape
pattern : symmetric.
3 areas: anterior, middle & posterior and resulting
values for each area were added together to yield
Calculation is done btw space required and space
Sp available: Includes Tooth measurement and Ceph
correction+ soft tissue modfn.
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.
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
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.
Soft tissue modf’n:
Thus teeth jaws, and soft tissue are all involved in
It is done by measuring the Z angle of Merifield and
adding ceph’ corr’ to it.
If the correctd, Z angle was grtr than 8o*,
then mandibular incisor inclination was
necessary(upto an IMPA of approx 92*)
If the corrected angle was less than 75*,
add’nl uprighting of the mandibular incisors
Upper lip thickness was measured from the
vermillion border of the lip to the greatest
curvature of the labial surface of the central
Total chin thickness was measured from the soft
tissue chin to the N-B line.
If lip thickness was greater than chin
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
There is no definite “recipe” for this
procedure- Rudolf Holtz
After 1 year
D are extracted
Eruption of 4 is accelerated
Erupting 4 is extracted
Canines erupt in alignment
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
Canines and incisors are aligned
Extraction of all D
Extraction of all 4’s
Extraction of all C’s
Canines erupt in
Premature loss of mandibular primary canine.
Usually accompanied by midline shift if
skeletal, dental , and profile patterns
overjet, overbite, axial inclinations,
and number, size , shape,
5-10mm or more arch length discrepancy
primary canine should be extracted.
1st premolar root is formed more than half,
primary 1st molar extracted.
1st premolar extracted as they emerge.
should be symmetrical.
If 5 mm
more in canine
Or with bimaxillary
should be to
as soon as
•Extract primary first molar
•Allow 1st premolar to erupt before
• Extract 1st premolar & primary
primary molars and
enucleation of first premolar at the
of second premolar rather than first
premolar should be considered.
Depends on type and severity of open bite
If open bite is dental, sequence will be similar
If skeletal, most posterior teeth in dental arch
should be extracted.
Includes extracting of enucleating permanent
molars or second premolar.
will increase after a serial
should be planned according to its severity
not it will worsen the problem.
If no mandibular crowding present,
Then management is by eliminating maxillary
Extract maxillary primary canine
Then extract primary first molar
Later maxillary first premolar is
interdigitation- Class I
second molar interdigitation: class II
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
requires concurrent orthopedic
appliance along with serial extraction.
class III malocclusion
- Poor candidates
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
most frequently used orthodontic
appliance with serial extraction are:
and mandibular lingual arches.
or removable headgears.
Effect of serial extraction alone on crowding:
relationships between tooth width, arch length,
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
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.
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
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.
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
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.
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.
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.
These conditions : normal occurrences for most
orthodontic treatments with a long-term follow-up
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.
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.
Has its both advantages and disadvantages.
Diagnostic skill, knowledge and experience are
“ SERIAL EXTRACTION IS NOT PANACEA FOR ALL