Serial extraction involves the planned removal of primary and permanent teeth to address crowding. It aims to guide unerupted teeth into improved positions through space creation. The document outlines the history, principles, objectives, indications, techniques and application of serial extraction for Class I and II malocclusions. Key techniques include Dewel, Nance, Tweed and Grewe's methods, which extract specific primary and permanent teeth in a sequenced manner to resolve crowding through physiologic tooth movement.

1. SERIAL EXTRACTION
DR SANTOSHNI SAMAL
MDS 2ND YEAR
DEPARTMENT OF
PEDODONTICS AND
PREVENTIVE
DENTISTRY

2. CONTENT
• Definition
• History
• Principles
• Rationale
• Objectives
• Indications
• Contraindications
• Diagnosis and treatment planning
• Procedure
• Techniques – Dewel, Nance ,Tweed,Grews
• Serial extraction in class I
• Serial extraction in class II

3. DEFINITION
• Serial extraction can be defined as the
correctly timed removal of certain
deciduous and permanent teeth in mixed
dentition cases with dentoalveolar
disproportion in order to alleviate crowding
of incisor teeth; allow unerupted teeth to
guide themselves into improved positions;
lessen (or eliminate) the period of active
appliance therapy (Tandon )
• Planned and sequential removal of the
primary and permanent teeth to
intercept and reduce dental crowding
problems. (Tweed)

4. Year Author
1600 Paisson First person who pointed the extraction procedure
in order to improve the irregular alignment and
crowding of teeth
1743 Bunon In his “Essay on the Diseases of the teeth”
proposed the removal of deciduous teeth to
achieve a better alignment of permanent teeth
1754
1757
1771
1814
1817
1846
1855
Lecluse
BoHunte
Hunter
Joseph fox
Duval
Robin
Harris
Removal of primary cuspids and bicuspids when
permanent incisors are irregular
HISTORY
Textbook of orthodontics by Gurkeerat singh 3rd edition

5. Year Author
1929 Kjellgren Coined the term ‘‘serial extraction’’ to
describe a procedure where some deciduous
teeth followed by permanent teeth were
extracted to guide the rest of the teeth into
normal occlusion
1940 Nance Presented clinics on his technique of
‘progressive extraction’ and has been called as
the Father of Serial Extraction philosophy
in the United States
1941 Hotz Named the procedure “Guidance of
eruption”. Term guidance of eruption is
comprehensive & encompasses all measures
available for influencing tooth eruption
Textbook of orthodontics by Gurkeerat singh 3rd edition

6. PRINCIPLES
• Whenever there is an excess of tooth
material as compared to the arch length,
it is advisable to reduce the tooth
material in order to achieve stable
results (selective extraction of teeth so
that the rest of the teeth can be guided
to normal occlusion).
• Many months of patient observation
is the rule rather than exception.
• It is important to know when not to
extract?
Dewel original article-indications, objectives and treatment procedures 1954

7. • Mandibular arch is the final
diagnostic guide with particular
emphasis on harmonius relation of
mandibular incisors to basal bone.
• Mandibular incisor stable only
when normally positioned over
basal bone.
• Equally important is the retention
of mandibular deciduous cuspids
until the normal time for their loss.
Dewel original article-indications, objectives and treatment procedures 1954

8. Rationale
• Class I malocclusion  Neuromuscular activity within
normal limits expansion makes tooth unstable
• Class II malocclusion  Definite change in the muscular
function expansion more valid
• Definite and excessive tooth material arch length discrepancy
(>10mm)
Textbook of orthodontics by Gurkeerat singh 3rd edition

9. Objectives
Textbook of orthodontics by Graber – Guidance of occlusion : serial extraction
Sno Treatment Year Remarks
1 Interceptive guidance 7.5- 12.5 yrs (Ideal) no
mehanotherapy
2 Initial period of interceptive
guidance + year of
multibanded treatment
7.5-11.5 yrs
11.5-12.5 yrs
Class I & II
3 Initial period of interceptive
treatment+ period of
interceptive guidance+
Second period of multibanded
treatment
8.5-9.5 yrs
9.5-11.5 yrs
11.5-13 yrs
Class II & III
4 A period of multibanded
treatment extending from 1.5- 3
yrs from age
11.5-14.5 yrs No serial extraction

10. INDICATIONS
Arch length deficiency and tooth size discrepancy
Premature loss of deciduous teeth
Unilateral deciduous canine loss /midline shifting
Lingual eruption of lateral incisors
Absence of physiologic spacing
Mesial drift of buccal segment
Canines erupting mesial to the lateral incisors
Abnormal eruption direction & sequence
Deleterious oral habits & Class I malocclusion showing
harmony between skeletal and muscular system
Abnormal primary canine root resorption
Flaring, ectopic eruption, ankylosis, etc.
Crowded both incisors with extreme labial
proclination
Gingival recession on labially displaced incisors

11. CONTRAINDICATIONS
Congenitally absent/missing lower 2nd premolars
Unilateral congenital absence of teeth ,abnormal tooth size,
shape, color, etc
Reverse overjet, deep bite, open bite, rotation, gross
malposition, cross bite, etc.
Extensive caries of permanent 1st molars
Cleft lip and cleft palate cases
Mild disproportion between arch length and tooth material
that can be treated by proximal stripping
Class I malocclusions with minimal space deficiency/spaced
dentition

12. Advantage Disadvantage
Treatment is more
physiologic
Cannot be applied in class II and III
malocclusion
The removal of deciduous
canine allows spontaneous
alignment of crowded incisors
Psychological trauma
Extraction of 1st premolar
before crowding allows
permanent canines to drift
into natural alignment
Extractions are carried out too early
this result in space loss or delayed
eruption of successors
Lessens the period of future
appliance therapy and cost of
treatment
Lower permanent canines may erupt
ahead of 1st premolar into extraction
space of the first deciduous molar,
impacting premolar and making its
removal difficult

13. Advantage Disadvantage
Psychological trauma associated
with malocclusion can be avoided
by treatment
Quite frequently patients require
appliance treatment.
Better oral hygiene is possible No single approach that can be
universally applied to all patients
Health of investing tissues is
preserved.
Treatment time is prolonged (2 to
3 years)
Lesser retention period is
indicated
Patient cooperation is needed
Patient has a tendency of
developing tongue thrust
Ditching or space can exist
between the canine and 2nd
premolar.

14. Diagnosis and treatment planning
• Study models
• Radiographs- IOPA, lateral cephalogram,OPG
• Photographs
• Case history
• Progress models, radiographs at regular interval
• Mandibular lingual supporting arch when indicated
• Proper sequence at proper time
• Short period of active treatment edgewise appliance
Textbook of orthodontics by Gurkeerat singh 3rd edition

15. HOTZ (1970)-Morphologic evaluation
• State of tooth eruption / root formation
• Size ratio of the deciduous and permanent teeth in labial/ buccal
segments
• Size of apical base
• Relation of size, arch width and supporting bone
• Probable sequence of eruption
• Congenitally missing teeth
• Position of unerupted canine, premolar & 2nd molars
• Intercuspation of 1st molars

16. TECHNIQUE AND STAGES IN SERIAL
EXTRACTION THERAPY
• Timing and sequencing for extracting primary and permanent teeth
 key to success.
• Serial extraction usually involves a period of incisor adjustment
followed by a period of canine adjustment.
• Diagnostic records are obtained (comprehensive assessment of the
dental, skeletal and soft tissues.)
• A tooth material-arch length discrepancy must ideally exist (not less
than 5 to 7 mm should exist to undertake this procedure. )

17. • Carey’s analysis in the lower arch and arch perimeter
analysis in the upper arch should be carried out.
• Mixed dentition analysis helps in determining the space
required for the erupting buccal teeth.
• The eruption status of the dentition is evaluated from an
orthopantogram (OPG).
• The skeletal tissue assessment should involve
comprehensive cephalometric examination to study the
underlying skeletal relation.
• The soft tissue assessment by clinical examination and
cephalograms help in the diagnosis

18. Removal of deciduous canine
• The purpose is to permit the eruption and
optimal alignment of lateral incisors.
• It prevents the mesial migration of canines into
severe malpositions.
• The four deciduous canines are removed as
upper permanent lateral incisors are erupting
(at about 8.5 years of age).
• The alignment of incisors should improve at the
expense of space for permanent canine

19. Removal of deciduous 1ST molars
• The 1st deciduous molars are removed in order to encourage the
early eruption of 1st premolar (at about 9.5 years of age).
• It is desirable that the 1st premolar should erupt in advance of
canines, although this is often not in the case of lower arch.
• It is sometimes done earlier in the mandible than maxilla to enhance
early eruption of lower 1st premolar.
• If the mandibular canine is erupting ahead of the mandibular 1st
premolar, either of two procedures should be carried out

20. • In a combined procedure, extract deciduous mandibular 1st
molars and surgically remove the unerupted permanent 1st
premolar
• To avoid the surgical procedure extract the deciduous mandibular
1st molars and, approximately six months later remove the
deciduous mandibular 2nd molars.
• This allows the unerupted 1st premolars to move distally in the
alveolar bone as the canine erupts.

21. REMOVAL OF ERUPTING FIRST
PREMOLARS
• When the upper permanent canine has just emerged through
oral mucosa, the 1st premolar should be extracted.
• This is the most important stage of serial extraction
procedure and it is essential to recheck that the case is
suitable for treatment by extraction of 1st premolars.
• All teeth must be present and sound and the permanent canines
must be mesially inclined.
• There must be crowding sufficient to justify the extraction of
1st premolars.

22. DESIRED OUTCOMES FOR SELECTION
OF TEETH FOR EXTRACTION
• Extraction of all primary canine self improvement in
crowding.
• Extracting all primary first molars earliest eruption of first
premolars reduce improvement in crowding.
• Enucleation of permanent canine  undesirable permits
distal translation of first premolars reduce resistance value
for final space closure.

23. PROCEDURE
• TWEED’S METHOD
• DEWEL’S METHOD
• NANCE’S METHOD
• GREWE’S METHOD

24. TWEED TECHNIQUE (DC4)-1966
ALL 1ST DECI
MOLARS
EXTRACTED (8
YRS)
MAINTAIN
CANINE
EXTRACT
ALL
PREMOLARS
WITH DECI
CANINE
CANINE
AND
INCISORS
ALIGNED
4-10 Month

25. DEWEL METHOD (CD4)-1978
• DECI CANINE
EXTRACTED
• 8-9 yrs
• DECIDUOUS 1ST
MOLARS
EXRACTED
• 9-10 yrs
• ERUPTION OF
PM
ACCELERATED
• CANINE ERUPTS
IN ALIGNMENT
MODIFIED
DEWEL

26. NANCE METHOD-D4C
EXTRACTION
OF DECIDUOUS
FIRST MOLARS
EXTRACTIONS
OF
PREMOLARS
EXTRACTIONS
OF DECIDUOUS
CANINE

27. MOYER’S METHOD-BCD4
EXTRACT ALL
DECIDUOUS
LATERAL
INCISORS
EXTRACT ALL
DECIDUOUS
CANINE
EXTRACT ALL
DECIDUOUS 1
MOLARS
EXTRACT ALL
1ST
PREMOLARS

28. GREWE’S METHOD
• Class I malocclusion with premature loss of a mandibular
deciduous canine Unilateral shift CD4 extract symmetric
• Class I malocclusion with severe mandibular anterior
crowding  CD4 extract
• Class I malocclusion where minimal mandibular anterior
crowding is 6-10 mm arch deficiencyD4C ,
• Dental class II with normal overjet CD4E
• Dental or skeletal class II with slight but minimal overjet
DE5

29. Serial extraction in class I treatment
• GROUP A- Anterior discrepancy : crowding
Extraction of primary canine (crescent)
Extraction of primary first molars
Extraction of first premolars
Multibanded treatment
Retention
Post retention

30. • GROUP B – Anterior discrepancy : Alveolodental
protrusion
EXTRACTION OF PRIMARY FIRST MOLARS
(knife edge)
EXTRACTION OF PRIMARY CANINE AND
1ST PMS
MULTIBANDED TREATMENT
RETENTION

31. • MIDDLE DISCREPANCY : IMPACTED CANINE
EXTRACTION OF PRIMARY FIRST MOLARS
EXTRACTION OF FIRST PREMOLARS
MULTIBANDED TREATMENT
RETENTION

32. • GROUP D- ENUCLEATION IN THE MANDIBLE
Extraction of the primary first molars and
enucleation of the mandibular first premolars
Extraction of primary maxillary canines
and maxillary 1st premolars
Multibanded treatment
Retention

33. • Group E : Enucleation in the maxilla and
mandible
Extraction of
primary canines and
primary first molars
and enucleation of
the 1st pms
Multibanded
treatment
Retention

34. • Group F– Alternative to enucleation
Extraction of primary
first molars
Extraction of primary
maxillary canines,
maxillary premolars
and primary
mandibular second
molars
Extraction of
mandibular first
premolars
Multibanded
treatment
Retention

35. • Group G- Interproximal reduction
• Group H- Congenital absence- maxillary incisor
and mandibular incisors

36. Serial extraction in class II
• GROUP A-Anterior discrepancy : Maxillary
protrusion
Extraction of
primary maxillary
first molars
Extraction of
primary maxillary
canine
& 1st premolar`
Extraction of
primary second
molars
Second period
of active
treatment
retention
Post
retention

37. • Group B- Middle discrepancy : Impacted maxillary
canine
Extraction of
primary first
molars
Extraction of
maxillary first
premolars
Second period
of active
treatment
Retention

38. • Group C – Posterior discrepancy : Ectopic
eruption in the maxilla
Extraction
of primary
maxillary
second
molars
Extraction
of primary
maxillary
first molars
Extraction
of primary
maxillary
canine
Multiband
edgewise
appliance
retention

39. • Group D- anterior discrepancy : maxillary
protrusion , mandibular incisor crowding
Extraction of
primary maxillary
first molars and
primary
mandibular
canines
Extraction of
primary
maxillary
canines,maxi
llary 1st pm
and primary
mandibular
1st molars
Extraction of
the
mandibular
first
premolars
Second
period of
active
treatment,
multibanded
edgewise
Retention

40. • Group E – Middle discrepancy : Maxillary and
mandibular canine and premolar crowding
• Extraction of
primary maxillary
first molars • Extraction of
primary maxillary
canine, max 1st pms,
primary mandibular
1st molars
• Extraction of
primary maxillary
second molars and
mandibular second
premolars
2nd period of active
treatment &
retention

41. • Posterior discrepancy : Maxillary and mandibular
molar crowding

42. GRABER 1971

49. References
• Text book of pediatric dentistry- nikhil marwah 4th edition
• Mc donald and avery dentistry for the child and adolescent
• Textbook of orthodontics by gurkeerat singh 3rd edition
• Textbook of orthodontics by Graber -5th edition