Extraction during orthodontic treatment...

1. EXTRACTIONS IN
ORTHODONTIC
TREATMENT
DEPARTMENT OF ORTHODONTICS
SAPPORO DENTAL COLLEGE AND HOSPITAL
Dr. Ha-Meem Fattaha
IS Batch- 26

2. What is extraction?
Painless removal of teeth from its socket is termed as
Extraction. It is one of the most common methods of
gaining space in the arch.

3. History of extraction in orthodontics
Since the early days of orthodontics the need for tooth
extractions has been discussed. In the early twentieth
century, Angle favored non-extraction orthodontic
treatment. But Tweed, one of Angle’s follower, noticed
relapse by treating patients without extraction. He re-
treated patients by extracting four premolars, thereby
achieving better functional and aesthetic results.
This controversy remains to this day. The diagnosis of some
malocclusions can be ambiguous in terms of the need for
extractions.

4. To extract or not to extract?
 Advantage of non-extraction approach
1. Less trauma to the pt.
2. Ease of treatment
3. Consumer demand
4. Short duration
5. Less effect on TMJ
6. Less effect on the vertical relationship
7. Less effect on smile width

5. To extract or not to extract?
 Advantages of extraction approach
1. Stability of the treatment
2. Less protrusive facial appearance
3. Controllable outcomes
4. Begg philosophy (tooth size reduction required to
compensate for dietary change)
5. Little gingival recession

6. Factors affecting the choice of extractions in
orthodontics
 General Factors
1. Medical condition
2. Age of patient - more difficult to close space in older pts.
Also in young patient other method of space provision
can be used
3. Patient cooperation where other method of space
provision can be used
4. Pathology
5. Gross Displacement
6. Abnormal morphology.

7. Continued…
 Factors specific to the malocclusion
1. Patient’s facial aesthetics and profile.
2. The A-P skeletal pattern
3. The vertical skeletal pattern. Extraction avoided in deep
bite and vice versa.

8. Diagnosis
According to Dewel , the challenge of orthodontic diagnosis is
not in those cases that reportedly require extractions or
those that clearly do not, but in a large group known as
borderline cases.
In any malocclusion, and particularly in a borderline case, it
is necessary to evaluate the patient’s dental, facial and
skeletal characteristics to establish a correct diagnosis and
effective treatment plan.

9. Diagnosis and Decision making:
MODEL ANALYSIS:
Kesling’s diagnostic setup
Carey’s arch perimeter
Howe’s analysis
Bolten tooth size ratio
CEPH. ANALYSIS
Tweed’s diagnostic triangle
Soft tissue profile analysis
CLINICAL EXAMINATION – profile, lip competence, VTO, age and
growth left.

11. In which conditions extraction is
necessary?
BUCHIN states-
 Arch length discrepancy of 3 – 4mm after 8 years of age
 Facial esthetics
 Basal bone disharmony –
1. Tweed’s triangle
2. ANB difference facial angle – less than 8 degrees
3. Amount of chin point from NB – pog
4. Anchorage requirement
 Pt. Co-operation

12. Continued…
SALZMANN states
 Labio lingual dental arch relation to facial plane
 Size of the gonial angle
 Axial inclination of the mandibular incisors
 Type of crowing present
 Direction of jaw growth
 Basal arch length thickness
 Distribution of soft tissue

13. Different extraction procedure
1. Balancing extractions
2. Compensating extractions
3. Phased extractions
4. Enforced extractions
5. Wilkinson extractions
6. Stobies extractions
7. Serial extractions
8. Driftodontics

14. Choice of teeth to be extracted
It depends on local conditions which include:
1. Direction and amount of jaw growth.
2. Discrepancy between size of dental arches and basal
arches.
3. State of soundness, position and eruption of teeth.
4. Facial profile.
5. Degree of dento-alveolar prognathism.
6. Age of patient.
7. State of dentition as a whole.

15. Continued…
The degree of crowding:
1. Mild , 1 to 4mm: Non extraction or second premolars
2. Moderate, 5 to 8 mm: First premolars or second
premolars
3. Severe, 9+ mm: First premolars

16. Indications of 1st premolar extraction
1. Convex profile with severe crowding.
2. Class II div I with deep anterior bite.
3. Class I with severe crowding.
4. Class I with bimaxillary protrusion.

17. Advantage:
1. Erupts before any other post teeth, after 6.
2. Strategically located close to the incisors.
3. Center of each half of arch .’. Ant & post crowding.
4. Protraction of molars not required
5. Contact between canine and 2nd premolar satisfactory.

18. Indications for 2nd premolar extraction
1. Good profile and Mild crowding
2. Flat profile and moderate crowding
3. Class II div 1 on skeletal class I and mild crowding
4. Mild Class III inter-arch relation and mild crowding in U
arch
5. Congenitally missing or impacted tooth.
6. Grossly destructed or heavy restored tooth
7. Abnormal root morphology.
8. Open bite.

19. Advantages:
1. Original facial contours retained without reduction of lip
profile
2. More esthetic along side canine.
3. Lesser tendency for extraction space to open in lower
arch.
4. Easy correction of Class II molar correction to Class I
molar relation.

20. Indications of 1st molar extraction:
1. Carious- beyond restoration .
2. Root canal treated, - than a perfectly good premolar.
3. Multi filled teeth- crown.
4. Premature extraction of 6, to preserve symmetry.
5. Facial considerations: large chin buttons & prominent
nose.
6. Open bite cases.

21. Indication of 2nd molar extraction
1. Caries, ectopic, rotated 2nd molar
2. Mild – moderate discrepancy with good profile.
3. Crowding in tuberosity area ,with a need for distal
movement of 1st molar.
4. 3rd molar in favorable angulation
5. Normal in size,shape & root area is sufficient

22. Advantage of 2nd molar extraction:
1. Disimpaction of 3rd molars
2. Faster eruption
3. Prevention of late incisor imbrication
4. Facilitation of 1st molar distalization
5. Distal movement only as needed to correct the overjet
6. Fewer “residual” spaces at the end of Rx
7. Less likelihood of relapse
8. Good functional occlusion
9. Good mandibular arch
10. Overbite reduction.

23. Indications of incisor extraction
Mandibular incisors:
1. Extreme crowding or protrusion.
2. Gingival recession & loss of overlying bone on labial
surface.
3. Lateral incisors severely damaged in young children.
4. Rarely-discrepancy in sizes of U & L incisors themselves,
1 incisor can be removed.
5. Rx time reduced with minimum facial change.

24. Continued…
Upper incisors:
Rarely indicated.
1. Unfavorable impaction of U incisor
2. Buccally or lingually blocked out lateral, with good
contact between central and canine.
3. Congenital missing of 1 lateral incisor
4. Dilacerated tooth.

25. Disadvantages of incisor extraction:
 Reopening of space
 Central Incisor.
 Danger of creating a tooth size discrepancy.
 Color difference of canine.

26. Canines: Indication for extraction
Impossible to bring in alignment.
Gross displacement buccally or lingually.
Does not show palatal cusp.

27. Summery
Extraction is justified as means of relieving excessive dental
crowding, in circumstances where growth cannot be
expected to provide relief. If a wrong decision is made or a
wrong mechanics is carried out, one really stands to do a
great disservice to the patient.
However, the extraction -non extraction debate continues,
suggesting that more objective information is needed. It is
hoped that the existence of more data will prevent the
debate.

28. References..
 Textbook of Orthodontics
By M.S Rani
 Orthodontics: Art and Science
S.I Balaji
 Journal of Orthodontics
University of Glasgow

file:///E:/Ortho/Extraction%20controversies%20in%20o
rthodontics%20%20certified%20fixed%20orthodontic%
E2%80%A6.html

29. THANK YOU!!!