To extract or_not_to_extract

To extract or not toTo extract or not to
extract…extract…
The diagnostic evaluationThe diagnostic evaluation
www.indiandentalacademy.com

OutlineOutline
 IntroductionIntroduction
 The extraction controversyThe extraction controversy
 Borderline casesBorderline cases
 WigglegramWigglegram
 Alternatives to extractionAlternatives to extraction
 Panel discussionPanel discussion
 SummarySummary

 ‘‘To extract or not to extract’- not theTo extract or not to extract’- not the
significance of ‘To be or not to be’significance of ‘To be or not to be’
 2 major reasons of extraction:2 major reasons of extraction:
- CrowdingCrowding
- Protrusion- camouflageProtrusion- camouflage
Given a choice- Non- extractionGiven a choice- Non- extraction

 Trauma & expense of surgeryTrauma & expense of surgery
 TMDTMD
 Flattened facial profilesFlattened facial profiles
 Dark buccal corridorsDark buccal corridors
 Pendulum- extremes of non extraction,Pendulum- extremes of non extraction,
routine extracions- cephalometric normsroutine extracions- cephalometric norms

The Extraction controversyThe Extraction controversy
 Extraction of deciduous teeth- ancient timesExtraction of deciduous teeth- ancient times
 Celsus, Fauchard- recommendedCelsus, Fauchard- recommended
 Controversy- permanent teeth extractionControversy- permanent teeth extraction
 Hunter- 17Hunter- 17thth
century- opposed- inhibited growthcentury- opposed- inhibited growth
 Early 1800s- extraction of 1Early 1800s- extraction of 1stst
premolars- Class IIpremolars- Class II
div 1 malocclusiondiv 1 malocclusion
 Delabarre- 1818- It is much easier to extractDelabarre- 1818- It is much easier to extract
teeth than to determine if it is absolutelyteeth than to determine if it is absolutely
necessarynecessary

 Kingsley- gave upKingsley- gave up
 Davenport- 1887- loss of important organsDavenport- 1887- loss of important organs
 Case- 1893- reintroduced- though archesCase- 1893- reintroduced- though arches
could be expanded- neither esthetics norcould be expanded- neither esthetics nor
stability satisfactory in the long runstability satisfactory in the long run
 Severe cases- 6%Severe cases- 6%
 Angle- 6Angle- 6thth
and 7and 7thth
publications- nonpublications- non
extractionextraction

 Wolff’s law- bone could be grown afterWolff’s law- bone could be grown after
teeth were moved off their basesteeth were moved off their bases
 Proper function of teeth could maintainProper function of teeth could maintain
them in normal positionthem in normal position
 Personal reason- disappointment in t/tPersonal reason- disappointment in t/t
outcome of Anna with premolar extractionoutcome of Anna with premolar extraction

 Case- 1911- the question of extraction inCase- 1911- the question of extraction in
orthodontiaorthodontia
 Martin Dewey- challenged CaseMartin Dewey- challenged Case
 Debate- early regulation, heredity, boneDebate- early regulation, heredity, bone
growth, evolutiongrowth, evolution
 Angle followers- won the day- 30 years-Angle followers- won the day- 30 years-
nonextractionnonextraction

 John Mershon, Joseph Johnson, GeorgeJohn Mershon, Joseph Johnson, George
Crozat- nonextractionCrozat- nonextraction
 1930- relapse1930- relapse
 First to analyze relapse scientifically –First to analyze relapse scientifically –
Alex Lundstrom- Stockholm, SwedenAlex Lundstrom- Stockholm, Sweden
 Apical base is deficient- crowded teethApical base is deficient- crowded teeth
corrected by orthodontic means- relapsecorrected by orthodontic means- relapse

 Charles TweedCharles Tweed

 Concerned with dental protrusions, facialConcerned with dental protrusions, facial
esthetics- extractionesthetics- extraction
 1940 Annual meeting of AAO- 100 cases1940 Annual meeting of AAO- 100 cases
 Position of mandibular central incisors-Position of mandibular central incisors-
Tweed facial triangle- 1936Tweed facial triangle- 1936
 Mechanics- rigid, time consuming- tipback,Mechanics- rigid, time consuming- tipback,
anchorage preparation, enmasseanchorage preparation, enmasse
movementsmovements

 Many visitors- Tuscan- seminars- 1941Many visitors- Tuscan- seminars- 1941
 1947- Tweed course- Charles H Tweed1947- Tweed course- Charles H Tweed
foundation for orthodontic researchfoundation for orthodontic research
 Raymond Begg- Australia- nonextraction- 2Raymond Begg- Australia- nonextraction- 2
yearsyears
 Studies of attrition in aborigines- crowding- resultStudies of attrition in aborigines- crowding- result
of lack of proximal wearof lack of proximal wear
 1928- extraction1928- extraction
 Stone age Man’s dentition- 1954, DifferentialStone age Man’s dentition- 1954, Differential
force in orthodontic treatment - 1961force in orthodontic treatment - 1961

 Robert StrangRobert Strang
 ConnecticutConnecticut
 Textbook of orthodontia- inviolability ofTextbook of orthodontia- inviolability of
intercanine and intermolar widthintercanine and intermolar width

 Hays Nance- Limitations of orthodontic t/tHays Nance- Limitations of orthodontic t/t
 Dentitions return to their originalDentitions return to their original
intercanine widthintercanine width
 Leeway spaceLeeway space

 End of 1960s- 50% American patients-End of 1960s- 50% American patients-
extraction treatmentextraction treatment
 Concept- orthodontic treatment could notConcept- orthodontic treatment could not
affect facial growthaffect facial growth

Recent trend towards nonRecent trend towards non
extractionextraction
 Extraction of all 4s- decreasedExtraction of all 4s- decreased

 Premolar extractions- search for stabilityPremolar extractions- search for stability
 Collapse of expanded arches- stableCollapse of expanded arches- stable
occlusion- no guaranteeocclusion- no guarantee
 Extraction – may not be stable- no reasonExtraction – may not be stable- no reason
to sacrifice teethto sacrifice teeth
 Other argument- If extractions areOther argument- If extractions are
unstable- nonextractions would be worseunstable- nonextractions would be worse
 No randomized clinical trial- extraction vsNo randomized clinical trial- extraction vs
non – ex in Class I crowdingnon – ex in Class I crowding

 General public – fuller lipsGeneral public – fuller lips
 Change from full banding- bonding- easierChange from full banding- bonding- easier
to expand- eliminating band spaceto expand- eliminating band space
 1980s- extractions- TMD1980s- extractions- TMD

 2 fold result- nonextraction t/t carried to2 fold result- nonextraction t/t carried to
extremeextreme
 Controversy over extractions continuesControversy over extractions continues
 Orthodontics- not yet an evidence basedOrthodontics- not yet an evidence based
specialityspeciality
 Therapeutic diagnosisTherapeutic diagnosis

What is a borderline case?What is a borderline case?
 Buchin- Borderline case- when extraction ofBuchin- Borderline case- when extraction of
teeth is required to reach stable and functionalteeth is required to reach stable and functional
occlusion , but when patient has good facialocclusion , but when patient has good facial
esthetics that could be disturbed by extractionsesthetics that could be disturbed by extractions
 Individual perception:Individual perception:
- Concept of esthetics- subjectiveConcept of esthetics- subjective
- Technical competenceTechnical competence
- Ability to motivate patientsAbility to motivate patients
- Understanding of growth and maturationUnderstanding of growth and maturation

 Borderline skeletal problemBorderline skeletal problem
 Borderline arch length discrepancyBorderline arch length discrepancy
 Localized malalignment of teethLocalized malalignment of teeth
 Skeletal – early T/t, dental – permanentSkeletal – early T/t, dental – permanent
dentitiondentition

Criteria for extractionCriteria for extraction
 Arch length discrepancy of 3-4 mm after 8Arch length discrepancy of 3-4 mm after 8
years of ageyears of age
 Facial esthetics:Facial esthetics:
- Will flattening middle and lower third ofWill flattening middle and lower third of
face improve esthetics?face improve esthetics?
- Will soft tissue drape be representative ofWill soft tissue drape be representative of
the skeletal scaffold, how much will chinthe skeletal scaffold, how much will chin
and nose grow?and nose grow?

- Competency of lipsCompetency of lips
- Sex, ethinicitySex, ethinicity
 Skeletal disharmony-Skeletal disharmony-
FMA less than 19 degrees, FMA > 38FMA less than 19 degrees, FMA > 38
degrees- no extractiondegrees- no extraction
 Patient cooperationPatient cooperation

Extraction Decision- MakingExtraction Decision- Making
Wigglegram- Rody, Araujo- 2002Wigglegram- Rody, Araujo- 2002
 Borderline cases:Borderline cases:
- Absence of dental or craniofacialAbsence of dental or craniofacial
anomaliesanomalies
- Permanent dentitionPermanent dentition
- Healthy periodontiumHealthy periodontium
- Skeletal Class ISkeletal Class I

 Wigglegram - 1Wigglegram - 1stst
use for orthodontic use-use for orthodontic use-
Vorhies & Adams – Down’s cephalometricVorhies & Adams – Down’s cephalometric
analysisanalysis

Dental VariablesDental Variables
1.1. Crowding- > 8mm- extractionCrowding- > 8mm- extraction
2.2. Curve of Spee- >6mmCurve of Spee- >6mm

3. Bolton Discrepancy- > 4mm- extraction3. Bolton Discrepancy- > 4mm- extraction
4. Peck & Peck index- MD/BL x 1004. Peck & Peck index- MD/BL x 100
 Mandibular central incisors- 88 – 92%Mandibular central incisors- 88 – 92%
 Mandibular lateral incisor - 90 – 95%Mandibular lateral incisor - 90 – 95%
88-95%- good anatomical shape88-95%- good anatomical shape
5. Irregularity index- Little5. Irregularity index- Little
Mandibular incisor alignmentMandibular incisor alignment

 Irregularity of 3.5-6.5 mm- mildIrregularity of 3.5-6.5 mm- mild
 > 6.5 mm- severe irregularity> 6.5 mm- severe irregularity

Cephalometric variablesCephalometric variables
First 4 evaluate vertical facial proportions,First 4 evaluate vertical facial proportions,
other 3 proclination of lower incisorsother 3 proclination of lower incisors
1.1. Relationship of horizontal planes-Relationship of horizontal planes-
SassouniSassouni

2. FMA- 20 degrees- skeletal deep bite2. FMA- 20 degrees- skeletal deep bite
3. SN- MP- Schudy- 30- 34 degrees3. SN- MP- Schudy- 30- 34 degrees
4. Jaraback’s ratio- 61- 69%4. Jaraback’s ratio- 61- 69%
5. IMPA- Margolis5. IMPA- Margolis
Tweed- 85- 95 degreesTweed- 85- 95 degrees
Varies according to mandibular planeVaries according to mandibular plane
inclination, ethinicityinclination, ethinicity
> 96 degrees- extraction> 96 degrees- extraction

6. FMIA- 60-70 degrees6. FMIA- 60-70 degrees
7. Distance between lower incisor to A- Pog7. Distance between lower incisor to A- Pog
- 2 to 3 mm- 2 to 3 mm

Facial VariablesFacial Variables
1.1. Distance between E- line and lower lipDistance between E- line and lower lip

 Lower lip- 2mm behind E lineLower lip- 2mm behind E line
Age & sex variation- -5 to 1 mm- RickettsAge & sex variation- -5 to 1 mm- Ricketts
2. Distance between B- line and lower lip2. Distance between B- line and lower lip
Lower lip- 2.5Lower lip- 2.5 ++ 1.5 mm ahead- Burstone1.5 mm ahead- Burstone
> 4mm- extraction> 4mm- extraction

3. Nasolabial angle3. Nasolabial angle
Drobocky & Smith- extraction of 4Drobocky & Smith- extraction of 4
premolars- increase in nasolabial by 5.2premolars- increase in nasolabial by 5.2
degreesdegrees
4. Upper lip morphology- Holdaway’s4. Upper lip morphology- Holdaway’s
analysisanalysis

 Borderline cases with strained lips- incisorBorderline cases with strained lips- incisor
retraction without altering soft tissue profileretraction without altering soft tissue profile
 Arnett & Bergman- avoid extraction in casesArnett & Bergman- avoid extraction in cases
with flaccid lipswith flaccid lips

4. Dental midline problems4. Dental midline problems
Severe dental midline shifts- favourSevere dental midline shifts- favour
extractionsextractions
Growth Status- Extraction safer in post-Growth Status- Extraction safer in post-
pubertal patientspubertal patients

Alternatives to extractionAlternatives to extraction
Expansion vs ExtractionExpansion vs Extraction
EstheticsEsthetics
- Lip fullness- Lip fullness

 At what point have incisors moved too farAt what point have incisors moved too far
forward?forward?
 >4 mm lip separation at rest- incompetent>4 mm lip separation at rest- incompetent
lipslips

- Size of nose and chinSize of nose and chin
Large nose or chin- expansionLarge nose or chin- expansion
At what point are the incisors retracted tooAt what point are the incisors retracted too
much to affect esthetics?much to affect esthetics?
Concave profile, thin lips- avoid extractionConcave profile, thin lips- avoid extraction

 Stability considerationsStability considerations
- Amount of arch expansionAmount of arch expansion
- Lower arch more constrained than upperLower arch more constrained than upper

Expansion by opening the midpalatal suture-Expansion by opening the midpalatal suture-
lower arch will follow upperlower arch will follow upper
But if limiting factor is cheek pressure- noBut if limiting factor is cheek pressure- no
significant differencesignificant difference
Excessive expansion- fenestration,Excessive expansion- fenestration,
dehiscence of molar, premolar roots- 50%dehiscence of molar, premolar roots- 50%
skeletal, 50% dental movementskeletal, 50% dental movement
12mm expansion- 3mm per side dental12mm expansion- 3mm per side dental

Contemporary extractionContemporary extraction
guidelinesguidelines
Class I crowding casesClass I crowding cases
 < 4mm discrepancy- non extraction< 4mm discrepancy- non extraction
 5-9 mm- borderline cases5-9 mm- borderline cases
 > 10 mm discrepancy- extraction> 10 mm discrepancy- extraction

 Presence of protrusion along withPresence of protrusion along with
crowding- dilemmacrowding- dilemma
 Lips are retracted 2/3Lips are retracted 2/3rdrd
of incisor retraction-of incisor retraction-
till lip competence is achievedtill lip competence is achieved

 Final set of guidelines:Final set of guidelines:
- If extraction spaces can be closed without- If extraction spaces can be closed without
retracting too much, expansion carried outretracting too much, expansion carried out
without proclining too much..without proclining too much..
Esthetics not affected a great dealEsthetics not affected a great deal
For masticatory function and oral health, itFor masticatory function and oral health, it
makes no difference either waymakes no difference either way

ReproximationReproximation
 ““Stripping is defined as the act ofStripping is defined as the act of
clinically removing part of the dentalclinically removing part of the dental
enamel from an interproximal contactenamel from an interproximal contact
area.” (AO 2007).area.” (AO 2007).
 Sheridan and FillionSheridan and Fillion
1985…..slenderization techchnique1985…..slenderization techchnique
currently incurrently in
useuse

INDICATIONS:INDICATIONS:
 Mild to moderate crowding in anteriorMild to moderate crowding in anterior
areas….class Iareas….class I
 Good oral hygieneGood oral hygiene
 Mild tooth material excess …. Bolton’s analysisMild tooth material excess …. Bolton’s analysis
 Post treatment relapsePost treatment relapse
 Tooth shape deviations (Peck & peck index)Tooth shape deviations (Peck & peck index)

CONTRAINDICATIONSCONTRAINDICATIONS
 SMALL TEETHSMALL TEETH
 RESTORED TEETH WITH NORMAL SHAPERESTORED TEETH WITH NORMAL SHAPE
 ENAMEL HYPOPLASIAENAMEL HYPOPLASIA
 POOR ORAL HYGIENEPOOR ORAL HYGIENE
 HIGH CARIES & PLAQUE INDEXHIGH CARIES & PLAQUE INDEX
 RECTANGULAR SHAPED TEETHRECTANGULAR SHAPED TEETH
 VERY YOUNG PATIENTSVERY YOUNG PATIENTS

Approximately 50% of the
interproximal enamel can be safely
removed ( Boese -AO 1980)
Fillión : Mesial surface of the first right molar
to the same surface of the left molar
10.2 mm of space in the maxilla
8.6 mm in the mandible.

AIR ROTOR STRIPPINGAIR ROTOR STRIPPING
Dr John J. Sheridan in JAN 1985.

“Air rotor stripping is a technique to remove controlled
amounts of enamel in the posterior segments to gain arch
length for retracting and aligning anterior teeth”(AJO FEB’94)
-Primarily in the buccal quadrants (upto 8mm space gain)
- Treatment philosopy …… Difficulties in adult extraction
Instability of expansion

Molar DistalizationMolar Distalization
 Patient with Class II molar- no obviousPatient with Class II molar- no obvious
skeletal deficiencyskeletal deficiency
 Acceptable facial estheticsAcceptable facial esthetics
 Upper incisors – normal, retroclinedUpper incisors – normal, retroclined
 Canines bucally blocked outCanines bucally blocked out
 Minimal arch length discrepancyMinimal arch length discrepancy
 Low MPALow MPA

C/IC/I
 Severe arch length discrepancySevere arch length discrepancy
 Proffit- 2-3 mm space on either sideProffit- 2-3 mm space on either side
 Skeletal Class IISkeletal Class II
 High MPAHigh MPA
 Fully grown patientsFully grown patients
 Too early- William Wilson- not before 11Too early- William Wilson- not before 11

Negatives of extractionsNegatives of extractions
 Tendency towards recrowding in lowerTendency towards recrowding in lower
anterior regionanterior region
 Deepening of anterior overbiteDeepening of anterior overbite
 Incomplete contact points, improperIncomplete contact points, improper
marginal ridges, plunger cusps- periomarginal ridges, plunger cusps- perio
problemsproblems
 Streamlining of face- large nose, big chinStreamlining of face- large nose, big chin
point, retrusive dentitionpoint, retrusive dentition

Comparison of the changes in facial profile afterComparison of the changes in facial profile after
orthodontic treatment with and without extractions,orthodontic treatment with and without extractions,
in "borderline" Class I crowding female patientsin "borderline" Class I crowding female patients
- Arch length discrepancy - 3 to 7mm- Arch length discrepancy - 3 to 7mm
- No severe incisor and lip protrusion and no- No severe incisor and lip protrusion and no
severe vertical discrepancysevere vertical discrepancy

- Soft tissue differences between two groups - endSoft tissue differences between two groups - end
of treatment - more protruded lower lip in non-of treatment - more protruded lower lip in non-
extraction patientsextraction patients
- Significant hard tissue difference between twoSignificant hard tissue difference between two
groups - only limited to- more labial inclinationgroups - only limited to- more labial inclination
of the incisors in non-extraction patientsof the incisors in non-extraction patients
- Borderline cases can be treated with satisfactoryBorderline cases can be treated with satisfactory
occlusions and esthetics either way. This is trueocclusions and esthetics either way. This is true
if expansion is managed so as not to produceif expansion is managed so as not to produce
too much protrusion, or space closure aftertoo much protrusion, or space closure after
extraction is controlled so as not to produce tooextraction is controlled so as not to produce too
much incisor retractionmuch incisor retraction

Interview- Buchin, Barrer, Fogel,Interview- Buchin, Barrer, Fogel,
Swain, AckermanSwain, Ackerman
1.1. If one makes a wrong decision inIf one makes a wrong decision in
borderline cases- health of dentition?borderline cases- health of dentition?
- CatastrophicCatastrophic
- Worsening of profile with age- concaveWorsening of profile with age- concave
- Forward mandibular growth, flattening ofForward mandibular growth, flattening of
MPA, growth increments in PogMPA, growth increments in Pog
- Soft tissue in chinSoft tissue in chin
- Effect of poor tooth relationship on healthEffect of poor tooth relationship on health
of dentition – not evidentof dentition – not evident

 Therapeutic diagnosisTherapeutic diagnosis
 Example in dermatologyExample in dermatology
 Anterior open biteAnterior open bite
 Therapeutic diagnosis- not ideal butTherapeutic diagnosis- not ideal but
responsibleresponsible
 Borderline casesBorderline cases
 When in doubt- nonextractionWhen in doubt- nonextraction

 In borderline cases- do you change facesIn borderline cases- do you change faces
or treat teeth?or treat teeth?
 Dental – without affecting labiolingualDental – without affecting labiolingual
position of lower incisors to preserveposition of lower incisors to preserve
existing facial contoursexisting facial contours

 Are we more concerned with the faceAre we more concerned with the face
rather than the patient?rather than the patient?
 Calvin Case:Calvin Case:
No matter how irregular the teeth, howeverNo matter how irregular the teeth, however
bunched, malaligned or malposed, they canbunched, malaligned or malposed, they can
always be placed in their respective places inalways be placed in their respective places in
the arches and in normal occlusion. Therefore,the arches and in normal occlusion. Therefore,
so far as the relations of the teeth to each otherso far as the relations of the teeth to each other
are concerned, no dental malposition should beare concerned, no dental malposition should be
taken as a basis for extraction. The only excuse,taken as a basis for extraction. The only excuse,
then, for the extraction of savable teeth must bethen, for the extraction of savable teeth must be
that it is inexpedient or impossible to correctthat it is inexpedient or impossible to correct
their positions in that way without producingtheir positions in that way without producing
facial protrusion."facial protrusion."
- Stability- Stability www.indiandentalacademy.com

This discussion of borderline cases seemsThis discussion of borderline cases seems
to celebrate the art of orthodontics asto celebrate the art of orthodontics as
opposed to the science of orthodontics. Inopposed to the science of orthodontics. In
the discussion we have seenthe discussion we have seen
cephalometric analyses and the use ofcephalometric analyses and the use of
various diagnostic materials. However,various diagnostic materials. However,
when the diagnostic material conflictedwhen the diagnostic material conflicted
with clinical experience, it seems to mewith clinical experience, it seems to me
that the decision was made in favor ofthat the decision was made in favor of
clinical experience. Is it the feeling of theclinical experience. Is it the feeling of the
panel that in borderline cases one is onpanel that in borderline cases one is on
safest ground when one relies on clinicalsafest ground when one relies on clinical
experience as the major contributing factorexperience as the major contributing factor
in diagnosis and treatment planning?in diagnosis and treatment planning?

 Facial balance with the major objective- clinicalFacial balance with the major objective- clinical
experienceexperience
 It is always a problem when someone asks aIt is always a problem when someone asks a
question and uses a term that has meaning toquestion and uses a term that has meaning to
him but perhaps a different meaning to the manhim but perhaps a different meaning to the man
answering the question. We refer to clinicalanswering the question. We refer to clinical
experience and diagnostic criteria. To me,experience and diagnostic criteria. To me,
clinical experience is only a measure of theclinical experience is only a measure of the
operator's ability. It varies with each of us. Ouroperator's ability. It varies with each of us. Our
clinical experience is "what we can do".clinical experience is "what we can do".

 Diagnostic criteria are generally specifics that weDiagnostic criteria are generally specifics that we
take from someone else such as a Tweedtake from someone else such as a Tweed
triangle or a Downs analysis. In our workingtriangle or a Downs analysis. In our working
practices we have to give preference to thepractices we have to give preference to the
clinical experience we have attained over theclinical experience we have attained over the
numbers that someone may have given us. So,numbers that someone may have given us. So,
if we do have a conflict, I think it is perfectlyif we do have a conflict, I think it is perfectly
legitimate to use clinical experience orlegitimate to use clinical experience or
therapeutic treatment in preference to sometherapeutic treatment in preference to some
arbitrary scale of which we are not completelyarbitrary scale of which we are not completely
sure. It may change tomorrow.sure. It may change tomorrow.

Mechanics in borderline casesMechanics in borderline cases
 Begg advantageous over edgewise:Begg advantageous over edgewise:
- Distal uprighting of upper and lowerDistal uprighting of upper and lower
molars- space gainingmolars- space gaining
……Dr. SwainDr. Swain

Summary- Century OrthodonticsSummary- Century Orthodontics
 All or nothing nature of premolarAll or nothing nature of premolar
extractions- different orthodontists –extractions- different orthodontists –
conflicting viewsconflicting views
 Each doctor has different gray betweenEach doctor has different gray between
extraction and nonextractionextraction and nonextraction

 Borderline casesno right answersBorderline casesno right answers
 Try to avoid extractions as much asTry to avoid extractions as much as
possiblepossible
 Esthetics, stabilityEsthetics, stability
 Conflict between esthetics, stability-Conflict between esthetics, stability-
estheticsesthetics
 Not that flat profiles, crowding-Not that flat profiles, crowding-
nonextractionsnonextractions

 Contrary to nonextraction believers- noContrary to nonextraction believers- no
TMDsTMDs
 Well treated extractions- no adverse effectWell treated extractions- no adverse effect
on facial profileson facial profiles
 Visualize patients with flat profiles withVisualize patients with flat profiles with
premolar extractionspremolar extractions
 Truth- tight facial structures – crowding-Truth- tight facial structures – crowding-
extractions- not vice versaextractions- not vice versa

 Most dished in – nonextractionMost dished in – nonextraction
 post hoc ergo propter hoc (after thispost hoc ergo propter hoc (after this
therefore because of this)therefore because of this)
 dark buccal corridors and a narrow smiledark buccal corridors and a narrow smile
are not “caused” by premolar extractions.are not “caused” by premolar extractions.

 Good selling point for premolarGood selling point for premolar
extractions- moderate crowding, wellextractions- moderate crowding, well
formed and positioned 3formed and positioned 3rdrd
molarsmolars
 no guarantee can be made that the thirdsno guarantee can be made that the thirds
will always come in with enough roomwill always come in with enough room

 Great deal of confusion about earlyGreat deal of confusion about early
expansion treatmentexpansion treatment
 Important difference between expanding aImportant difference between expanding a
constricted upper arch to match a normalconstricted upper arch to match a normal
lower archlower arch
 significantly expanding both arches in asignificantly expanding both arches in a
patient whose arches may be narrow, butpatient whose arches may be narrow, but
are in a normal transverse occlusalare in a normal transverse occlusal
relationship to each otherrelationship to each other

 Possible to upright lingually verted lowerPossible to upright lingually verted lower
posterior arches (which may have collapsed in,posterior arches (which may have collapsed in,
to compensate for a narrow maxillary arch), it isto compensate for a narrow maxillary arch), it is
not possible to expand the mandibular basalnot possible to expand the mandibular basal
bone - is no suture to distract as in the maxillabone - is no suture to distract as in the maxilla
 One of the most established - stability of theOne of the most established - stability of the
lower inter-canine widthlower inter-canine width
 Expansion beyond the original width - almost aExpansion beyond the original width - almost a
guarantee of collapse and recrowdingguarantee of collapse and recrowding

In an attempt to avoid first premolar extractions,In an attempt to avoid first premolar extractions,
various alternatives can be considered:various alternatives can be considered:
- Expanding the arch, especially in flat-faced- Expanding the arch, especially in flat-faced
individual- preferable to extractions - unstableindividual- preferable to extractions - unstable
correction - retention will be neededcorrection - retention will be needed
- Patients with good posterior occlusion, good- Patients with good posterior occlusion, good
upper arch with relatively small upper incisors,upper arch with relatively small upper incisors,
moderately severe lower crowding, minimalmoderately severe lower crowding, minimal
overbite - extraction of lower incisoroverbite - extraction of lower incisor
Should be evaluated very carefully- untreatableShould be evaluated very carefully- untreatable
problem with excessive overjet/overbiteproblem with excessive overjet/overbite

 Interproximal enamel reduction (IPR) canInterproximal enamel reduction (IPR) can
provide a moderate amount of room butprovide a moderate amount of room but
should be reserved for older patients.should be reserved for older patients.
Excessive IPR as an initial treatmentExcessive IPR as an initial treatment
complicates the orthodontist’s ability tocomplicates the orthodontist’s ability to
correct minor relapses in the future.correct minor relapses in the future.

 Consider extraction of second premolars ratherConsider extraction of second premolars rather
than first premolars.than first premolars.
 Theoretically- reduces the amount of anteriorTheoretically- reduces the amount of anterior
retraction when only some space is needed forretraction when only some space is needed for
crowding and facial profile is acceptablecrowding and facial profile is acceptable
 Works best when second premolars resembleWorks best when second premolars resemble
the first, but large, molar-like second premolarsthe first, but large, molar-like second premolars
may provide too much room and small, canine-may provide too much room and small, canine-
like first premolars may not work against firstlike first premolars may not work against first
molarsmolars

 No right answers in borderline casesNo right answers in borderline cases
 Both T/t performed by competentBoth T/t performed by competent
orthodontists- satisfactory results- neitherorthodontists- satisfactory results- neither
perfectperfect

 Borderline cases- greatest responsibilityBorderline cases- greatest responsibility
 SensitiveSensitive
 if the wrong decision is made or if theif the wrong decision is made or if the
mechanics are not carried out correctly,mechanics are not carried out correctly,
one really stands to do a great disserviceone really stands to do a great disservice
to the patient.to the patient.

Extractions are just a tool,Extractions are just a tool,
not good or bad innot good or bad in
themselves. Used right, theythemselves. Used right, they
improve the quality ofimprove the quality of
treatment, used wrong theytreatment, used wrong they
may create a poor result.may create a poor result.

THANK YOUTHANK YOU

To extract or_not_to_extract

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