serial extraction

SERIAL EXTRACTION

INTRODUCTION

• Early orthodontic interventions are often initiated in the

developing dentition to promote favourable

developmental changes and remove or suppress those

that are unfavourable.

• Early interceptive orthodontics can eliminate or reduce

the severity of a developing malocclusion, the complexity

of orthodontic treatment, overall treatment time and

cost.

• It also improves self-esteem in the subjects and parental

satisfaction.

• However, lack of awareness among school children,

parents and primary-care personnel (dental nurses and

dental officers) result in patients not being referred for

timely interceptive intervention.

• Serial extraction procedures have been of interest to

dentists for many years.

INTRODUCTION

PROCEDURES UNDERTAKEN IN INTERCEPTIVE ORTHODONTICS

1. Serial extraction

2. Correction of developing cross bite

3. Control of abnormal habits

4. Space regaining

5. Muscle exercises

6. Interception of skeletal malrelation

7. Removal of soft tissue or bony barrier to enable eruption of teeth

HISTORICAL PERSPECTIVE

• Robert Bunon (1743)- published in his “Essay on

Diseases of the Teeth” the principles of early

treatment, associated with extraction of primary

teeth followed by removal of permanent teeth.

• Kjellgren- is credited with the introduction of the

term, “serial extraction”

DEFINITIONS

• Defined as ‘Interceptive orthodontic procedure that

helps to resolve tooth crowding of 8 mm or more by

creation of space in arch during development of

occlusion by a serial system of tooth removal, which

usually begins with a deciduous tooth, leading to

extraction of all first premolars’.

• Serial extraction is an interceptive procedure, which is

more appropriately termed as ‘eruption guidance’.

• Defined as, ‘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’.

DEFINITIONS

PRINCIPLES OF SERIAL EXTRACTION

1. ARCH-LENGTH: TOOTH MATERIAL

DISCREPANCY

2. PHYSIOLOGIC TOOTH MOVEMENT

3. REMOVAL OF DECIDUOUS CANINE

4. REMOVAL OF 1ST DECIDUOUS MOLARS

5. REMOVAL OF ERUPTING 1ST PREMOLARS

1. ARCH-LENGTH: TOOTH MATERIAL DISCREPANCY

• When an excess of tooth material as

compared to arch length is seen; tooth

material should be reduced.

• This principle is utilized where tooth material

is reduced by selective extraction of teeth to

guide unerupted teeth into normal occlusion.

2. PHYSIOLOGIC TOOTH MOVEMENT

• Physiologic tendency to move towards the extractionspace. Thus by selective removal rest can be guided bynatural forces.

• INDICATIONS-– Premature loss of deciduous teeth

– Arch–length deficiency & tooth-size discrepancy

– Absence of physiologic spacing

– Lingual eruption of lateral incisors

– Unilateral deciduous canine loss and midline shifting

– Canines erupting medial to lateral incisors

– Mesial drift of buccal segment

– Abnormal eruption direction and eruption sequence

– Flaring, ectopic eruption, ankylosis etc.

– Crowded incisors with extreme proclination

– Deleterious oral habits

CONTRAINDICATIONS-

– Congenitally absent/missing lower 2nd premolars

– Extensive caries of permanent 1st molars

– Severe class II and class III malocclusions of dentalas well as skeletal origin

– Unilateral congenital absence of teeth

– Abnormal tooth size, shape, colour etc

– Cleft lip and cleft palate cases.

– Reverse overjet, deep bite, open bite, rotation, grossmalposition, cross bite, etc.

– Spaced dentition

– Class I malocclusion with minimal space deficiency

– Mild disproportion between arch length & toothmaterial.

ADVANTAGES-

– Treatment is more physiologic

– Removal of spontaneous alignment of crowdedincisors

– Extraction of first premolar before crowding allowspermanent canines to drift into natural alignment

– Lessens period of future appliance therapy and cost oftreatment.

– Physiologic trauma associated with malocclusion canbe avoided by treatment of malocclusion at an earlyage

– Better oral hygiene reduces risk of caries

– Health of investing tissues is preserved

DISADVANTAGES-

– Procedure cannot be applied in class II and class III malocclusion cases.

– Psychological trauma: unpleasant for a child to have 4 teeth extracted each time of 4 occasions.

– Treatment time is prolonged as it is carried out in stages over 2-3 years , thuds patient cooperation is needed.

– If extraction is carried out too early, may result in space loss or delayed eruption or permanent successor.

– Lower permanent canines erupt ahead of 1st premolar into extraction space.

– No single approach that is applied universally.

TECHNIQUE AND STAGES IN SERIAL EXTRACTION

DIAGNOSIS AND TREATMENT PLAN

• Deciding on timing and sequencing for extracting primary &

permanent teeth is - key to success.

• Technique of serial extraction involves a period of incisor

adjustment followed by canine adjustment.

• Diagnostic records are obtained by study model, periapical

radiographs, panoramic and cephalometric radiographs.

• Diagnostic exercise involves- comprehensive

assessment of the dental, skeletal, soft tissues. To

look for

– Tooth material-arch length discrepancy (5-7 mm)

• Study model analysis be carried out- arch length

discrepancy.

• For lower arch- CAREY’S ANALYSIS & for upper arch-

ARCH PERIMETER ANALYSIS.

• MIXED DENTITION ANALYSIS- determines space

required for erupting buccal teeth.


• Eruption status of dentition is evaluated froman orthopantogram (OPG).

• Skeletal tissue assessment should involvecomprehensive cephalometric examination tostudy underlying skeletal relation.

• Soft tissue assessment by clinical examinationand cephalograms help in diagnosis.


3. REMOVAL OF DECIDUOUS CANINE

• Purpose- to permit eruption and optimal alignment

of lateral incisors.

• Prevents mesial migration of canines into severe

malpositions.

• 4 deciduous canines are removed as upper

permanent lateral incisors are erupting (at 8.5 years

of age).

4. REMOVAL OF 1ST DECIDUOUS MOLARS

• 1st deciduous molars removed for early eruption of 1st

premolar.

• Best is if premolar roots are half formed (9.5 years).

Desirable is 1st premolar to erupt in advance of canines,

though often not seen.

• If mandibular canine is erupting ahead of mandibular 1st

premolar, either of two procedures :

– If combined procedure, extract deciduous mandibular 1stmolars & remove surgically unerupted permanent 1st premolar,

– To avoid surgical procedure extract deciduous mandibular 1stmolars & six months later remove mandibular 2nd molars.

5. REMOVAL OF ERUPTING 1ST

PREMOLARS

• When upper permanent canine has just erupted, 1st

premolar to be extracted.

• Most important stage of serial extraction procedure

and it is essential to recheck that case is suitable for

treatment by extraction of 1st premolars.

• Indication-

– Sufficient crowding for extraction of 1st premolars.

– All teeth must be present and sound and the permanent

canines must be mesially inclined. There must be

Methods have beenproposed for serial extraction therapy

1. Dewel’s method (CD4) usually followed inlower arch

2. Tweed’s method (D4C) can be followed ineither arch

3. Nance method (D4C) can be followed ineither arch.

• Tweed (1966)- if diagnosis shows discrepancy exists between

teeth and basal bone ; and if patient is between 7 ½ to 8 ½

years, Serial Extraction to be carried out.

Extraction Sequence is:

• At 8 years all deciduous molars are extracted.

• Maintain deciduous canines to retard eruption of permanent

canines.

• After 4-10 months, Extraction of all four 1st premolars

followed by deciduous canines be done, 4-6 months prior to

eruption of permanent canines.

• Any irregularities in mandibular incisors if not too severe, get

corrected themselves.

Tweed method of serial extraction D-C-4

3 stages in Serial Extraction Therapy:

• Removal of deciduous canines : at 8-9 years foralignment of incisors.

• Removal of first deciduous molars: after 1 year so thateruption of 1st premolars is increased.

• Removal of 1st premolars: to permit permanent caninesto erupt into place.

Indications of Dewel’s method:

• Mild crowding in anterior region. Early exfoliation of uni or bilateral deciduous canines.

• This maneuver is seldom successful in the lower archbecause the normal sequence is for the canine toerupt ahead of the first premolar In class Imalocclusions, especially the Ist premolar may bepartially impacted between canine and 2nddeciduous Molar .

• Hence the orthodontist may vary the first procedureof extracting the lower deciduous canines andextract the first deciduous molars in lower arch to tipthe eruption scales in the direction of first premolar.

Dewel method of serial extraction C-D-4

Nance method of serial extraction D-4-C

Indications: When crowding seen in

central incisor region

– Stage I (Extraction of all deciduous lateral incisors). For

alignment of central incisors.

– Stage II (Extraction of all deciduous canines after 7-8

months). For alignment of lateral incisors and provides

space for lateral incisors.

– Stage III (Extraction of all deciduous first molars). For

eruption of all first premolars.

– Stage IV (Extraction of all first premolars after 7-8

months). Provides space for canines.

Moyer method of serial extraction B-C-D-

4

SELECTION OF TEETH FOR EXTRACTION

• No single technique for Serial Extraction. It is a long-range

guidance program.

• Usually child is 7-8 years of age when he/she brought to the

pedodontist. At this time the maxillary and mandibular central

incisors are usually erupted, but inadequate space in to allow

normal eruption and positioning of lateral incisors.

• In some cases, mandibular lateral incisors have already

erupted but they are usually lingually positioned and rotated.

• Complete diagnostic records be made and studied- to gain

sufficient arch length & to provide a stable and healthy

occlusion.

Selection of teeth for extraction:

4. Naragond A, Kenganal S. Serial Extractions – A Review. IOSR Journal of Dental and Medical Sciences (JDMS). 2012 ;3: 40-47

SELECTION OF TEETH FOR EXTRACTION

ROLE OF THE PEDODONTIST

• Pedodontist and orthodontist are mutuallydependent on each other’s skills for treatment.

• Ideal plan for pedodontist is to observe the problem,make a decision that a serial extraction might beappropriate, explain the plan to parents and referpatient to orthodontist.

• Next orthodontist should explain serial extractionplan to parents as well as advise them that furtherorthodontic treatment may be needed.

• Finally, pedodontist will proceed with planned sequence of extractions.

CONCLUSION

• The procedure known as serial extraction is a

program of patience, of continuous observation and

study, of proper timing and of delay and

postponement until growth and development have

accomplished their mission.

• Much greater importance is

– That developing dentition receives competent supervision,

– that no teeth of any kind be removed prior to most precise

and exacting case analysis,

– That case analysis be repeated preceding and subsequent

extraction

REFERENCES

1. Nikhil Marwah. Textbook of pediatric dentistry3ed.1009-1018

2. Ralph e. Mcdonald. Dentistry for the Child and Adolescent. Eighth edition. 2004, Mosby, Inc.

3. Kharbanda OP. textbook of orthodontics.


5. Al Hummayani FM. Modified serial extraction treatment in a patient with congenitally missing lower second premolars. J Orthodont Sci 2015;4:92-6.

6. Jimmy C. Boley. Serial extraction revisited: 30 years in retrospect. American Journal of Orthodontics and Dentofacial Orthopedics. 2002; 575-77.

serial extraction

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