Professional Documents
Culture Documents
*Historical review.
*Reasons for Extraction.
*Factors determining the needs for extraction.
*Analysis made to determine whether to extract or not.
*Determination of space needed for alignment of teeth.
*Controversy regarding the effects of extraction.
*Factors considered in chosen the teeth for extraction.
*Choose of tooth for extraction.
*Compensating Extraction.
Historical review
The role of extraction in orthodontics was recognized by John Hunter 1771
in his natural history of the teeth.
Spooner 1839 advised the extraction of four premolars or first molars when
defective.
Pierce writing in the Dental cosmos of October 1859," advocated extraction
in teeth crowding as a mean for simplifying orthodontic procedures.
In 1887 Angle wrote on his new system to regulate and retain the teeth. He
stated that, if the teeth were placed in their proper occlusal relationship, normal
function would be developed the supporting bone to hold them in this position. In
that same year, the first edition of his book, on the same subject was published.
Other editions supposedly followed up to 1897 when the fifth edition, expanded
in scope, came out.
Farrar 1888 Considered Judicious extraction an essential request for the
prevention and correction of irregularities.
In 1896 Calvin case published an article regarding the need for extraction to
correct facial deformities.
Angle 1900 in the sixth edition of his book Malocclusion of the teeth
describes extraction for the relief of crowding and in the treatment or various
types of Malocclusion.
In a 1902 article, Angle set forth his line of reasoning toward the
development of his treatment philosophy. In this article, Angle states that my
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belief is that if we would confer the greatest benefits upon our patients from an
aesthetic standpoint we must work hand in hand with nature and assist her to
establish the relations of the teeth as the Creator intended they should be, and not
resort to mutilation .
In 1903 Case published an article in which he takes issue against the
injudicious extraction of permanent teeth.
Ottlengui in 1905 stated that, in an article published in 1907 in items of
interest, by this time one might almost say that the question of the hour was to
extract or not? Many orthodontists were arguing that extraction is almost a crime
and even a new word was coined for those who ruthlessly remove sound teeth from
so called crowded arch, and we heard much of odontocides. On the other hand men
long counting as experts in this branch of work still argued that often either for
reason of expediency or for actual benefit to the physiognomy, extraction was
permissible and even advisable.
A cothinker and supporter of Case, Matthew Cryer also published an article in
1905 in which he defends the use of extraction.
In 1907 the seventh edition of Angles book was been published which was
been completely stripped of all extraction case materials present in the sixth
edition. In this edition, Angels has been said that extraction plays no part in
orthodontic treatment, on the basis that if crowded teeth are aligned in correct
relation to each other, the improved function of the masticatory system will result
in growth of the jaws, which in turn will create adequate space for the dentition.
Since then he has always been considered the leading exponent of non extraction
technique . Thus , the major concept of orthodontic in these early years was one of
the expansion outward to a greater arch to eliminate individual teeth irregularities .
In the Extraction Debate of 1911," at this 1911 meeting of the National
Dental Association Calvin, Case presented an article entitled the question of
extraction in orthodontic. In this article he discusses the causes as he believes it is
intimately bound up in the discussion of extraction. He claims that the writings of
the new school (Angle) say that the causes of malocclusion are local , whereas
Case claims that they partly at least, arise from the law of heredity and from other
laws that govern the development of plants and animals, and especially to laws that
govern the mixture of dissimilar types.
This is not the first time that Case queried this line of thinking. In 1905 he
wrote, But why enter such a field of doubt, of danger, and of possible failure,
merely to satisfy a sentiment that God does not make the mistake of placing in the
mouth of the human individual more teeth than is necessary for perfect harmony in
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all physical and aesthetic relations? Why ignore the possibility and the frequent
undoubted fact that inherited inharmonious in contiguous structures over which we
have no control made it impossible for us to place all of the teeth in the arch
without fulfilling the designs of an inherited deformity. In my humble estimation it
should be the highest aim of the orthodontist to remove without hesitation such
portions of those naturally produced anatomical disharmonies as are within his
reach, and which characterize the principal deformity, instead of attempting to
carry out in so limited a degree the original designs of the Maker when he
fashioned an Apollo. (The Apollo reference her is a very sophisticated thrust at
Angle whose concept of beauty was based on this statue.).
On other area of controversy between Case rational school and Angles
new school. Angles group believed that bone could be induced by mechanical
means to grow beyond its inherent size, especially the mandible. Cases group
believed otherwise. In this area Case wrote that The correctness of the statement
that the mandible will grow to a harmonizing size will depend entirely upon
whether it has been stunted in normal growth development, which is quietly
improbable, unless we assume the absurdity that the same cause at the same time
produced the over-development of the upper jaw. Malrelations of this character
point directly to heredity.
It is more than likely that Charles Tweed was familiar with Cases concept of
extraction because Tweed was extremely unhappy with the faces he was
producing. The idea of treating cases again with extraction formed the basis of his
further work, which leads to the formulation of what is become known by Tweed
philosophy.
backward movement of the upper anterior teeth require the removal of a teeth to
provide spaces.
BAL
Tooth material
the 12 teeth anterior to the second molar if the basal arch is sufficient large to
accommodate all of the teeth. Case between 37- 44% may require extraction of
first premolar. When the premolar basal arch width is larger than the premolar
width at the cuspal region, than the basal arch is sufficient to allow expansion at
the premolars. This permit arrangement of crowded anterior teeth in more regular
manner.
Kesling diagnostic setup
The teeth are cut from the cast at the level of A and B points then repositioned
according to Tweed formula FMIA = 65 o . This method determine the
followings:-If the case is indicated for extraction or not and aid in choosing the teeth to
be extracted.
- The amount of the space created, by extraction and the tooth movement
necessarily to close the space.
- It is best mathematical representation of the problem during the mixed
dentition.
- Help in determine the type of anchorage, either minimum, moderate or
maximum anchorage.
Harvold symmetrograph
The symmetrograph is a transparent plastic device with an inscribed grid . The
midline of symmetrograph is superimposed over the median palatine raphe. This
quickly give us information about the followings :- Arch asymmetry .
- Drifted, tipped and rotated teeth.
- Also it is useful in planning individual tooth movement and determination of
appliance design .
Peck and Peck analysis
Many studies indicated that deviations of crown shape influence and
contribute to the mandibular incisor crowding . Peck and Peck construct an index
using the mesiodistal and faciolingual dimensions in the form of a mesiodistal
( MD) over faciolingual ( FL )ratio. The index equals the MD crown diameter in
millimeters divided by the FL crown diameter in millimeters and multiplied by
100. They also adapted numerical ranges as clinical guidelines for the maximum
limit of desirable MD, FL index values for the lower incisors : 88 - 92 for the
mandibular central incisors and 90 - 95 for the mandiblular lateral . Lower incisors
within or below the ranges must be considered favorably shaped for good
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alignment. Any lower incisor with an MD/FL index above these ranges , however,
possesses a crown shape deviation which may influence or contribute to the
crowding phenomenon. It can be seen, therefore, that reaproximation can function
as an exacting procedure to correct deviations of the mandibular incisor tooth
shape and to help achieve post-treatment stability. The minor correction require
removing 2 mm. from each side.
II-Cephalometric analysis
a) Tweed method
Tweed considered that, the lower incisors should be uprighted over the basal
bone to achieve harmonious and symmetric occlusal and facial balance and to gain
a stable result.
When the teeth in the dental arch cant be placed into regular alignment
without increasing the axial procumbency of the incisors, it become necessary to
reduce the number of the teeth to be accommodated in the arch.
Tweed diagnostic facial triangle :It is the basis for diagnosis, treatment planing and prognosis. It consists of
the following :
FMA (FH-MP) = 25 o .
IMPA ( 1 -Mp) = 90 o .
FMIA ( 1 -FH) = 65 o .
* Roles of FMA in determining the need for extraction :1-When the FMA = 20 o 30o , the correct position of
The prognosis for reducing the alveodental progonathism varies from good to those
nearest 30 o to fair to those nearest 35 o .
3- When the FMA = 35o 40 o , the prognosis for reducing the alveodental
progonathism varies from fair at 35 o and unfavorable at 40 o .
4- When the FMA is over 40 o the prognosis is extremely unfavorable. In
some cases, the removal of the teeth in 40 o or more FMA detracts from father than
enhance facial appearance.
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Tweeds formula for treatment is given as follow :1- Non extraction - FMIA = 65 o or grater and sufficient arch length.
2- Borderline
- FMIA = 62 o - 65 o with sufficient arch length.
3- Extraction
- FMIA = 62 o or less.
b) Stiener analysis
He relate the lower incisors to NB line and use a linear measurement of 4
mm and angular measurement of 25 o .
He uses the rule of thumb that one-third of the space is lost and that every
degree of distal or mesial movement of the lower incisors represents the 2.5 mm
.In liner movement.
Steiner bases his decision regarding extraction of teeth upon number of
factors; the discrepancy between space available and space required the amount of
room for expansion and its maintenance; the distance mesially of distally which he
must position the lower incisor to achieve his concept of a well-balanced face; the
possibility of relocation of the lower first permanent molar the possibility of
utilizing any of the space left by the exfoliation of the second deciduous molars;
the amount of space consumed by the use of intermaxillary elastics during
treatment; and the space which might be gained through extraction of teeth. A
combination of these factors and their net results determine whether or not
extraction is indicated.
c) Holdaway analysis
He has proposed that the lower incisor and pogonion be related to each other
by the reference to the line NB : both are liner measurement expressed in mm . The
ratio of this measurement to each other , and not their value , is important .
Anything within 2 mm. of an equal ratio is in very good facial balance. If the ratio
is off 3 mm., Holdaway will tolerate it ; if there is a 4 mm. difference, he extracts
to return to the 3 mm. variance.
Right + Left
+ 0.5
2
of space.
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2- Soft tissues
Orthodontists have long recognized that the extraction especially the premolar
often is accompanied by changes in the soft tissues profile. At times these changes
will result in improvement in the facial profile. At other times, extraction can lead
to what is sometimes called the Orthodontics look or dished - in profile. For
this reason , there has been a tendency to avoid extraction of premolar wherever
possible and, in some cases, to extract second rather than first premolars.
Lo and Hunter studied the nasolabial angel changes that occurred in the
treated Class II,Division 1 malocclusion. The patients had a minimum of 3 mm.
upper incisor retraction at treatment completion.
They summarized the
followings:1-The nasolabial angel increased with the increase in the maxillary incisor
retraction.The mean ratio of increase was 1.6 degrees to 1 mm.
2-There was a strong and significant correlation between the change in the
nasolabial angel and the increase in lower face height. The average ratio of
increase was 2.2 degrees to 1 mm.
3- The response of the nasolabial angel from the extraction group was not
significantly different from that of the nonextraction group.
Looi and Mills, studied the effect of extraction versus non extraction on the
soft tissue profile. They concludes:1. Following retraction of upper incisor teeth in class II, Division 1 malocclusion,
the upper lip drops back to a certain extent and its probably desirable in most
cases. Where the incisors are retracted excessively, the lip do not fall back to a
corresponding extent and any further dropping back may be more associated with
backward movement of point A and therefore removing support from the base of
the lips.
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2. Retraction of the lower incisors has more effect on the lower lip, which seems to
follow the incisors closely. Although in some cases this may be desirable, in many
cases it is not and retraction of the lower incisors should be avoided.
3. The reduction of overjet has the effect of uncurling both lips; this enables
them to be held together without undue effort.
4. There is a wide individual response in the reaction of the soft tissues to change
in the underlying hard tissues; it is not possible to predict the effect on the lips of a
given movement of the teeth.
Talass etal, analyzed the soft tissue profile change that result from retraction
of maxillary incisors at minimum of 3 mm either with or without extraction. The
result of this study summarized as following:1. The upper lips were retracted mean 3.7 .
2. The Anteroposterior position of the lower lip seem to be unchanged.
3. Increased nasolabial angle by mean of 10 .5
4. Decrease of interlabial gap by about 2.4 mm .
5. Increased lower lip length by mean of 3.4 mm .
6. Increase upper lip thickness by mean of 2.3 mm .
7. Increase the soft tissue lower face height.
They considered three measurements that were of clinical significance , this
measurements are the upper lip retraction, the lower lip length and the increase in
the labiomental angle .
Drobocky and Smith examined the change in the facial profile during
orthodontic treatment with extraction of four first premolars. They concluded that
the negative effect of extraction on the facial profile are false. Clearly the great
majority of patient exhibit controlled amount of profile change that produce
improvement in facial esthetics. They also observed that there is a great individual
variability in the effect of treatment on the soft tissue profile.
Young and Smith , compare the soft tissues profile changes of extraction and
nonextraction treated patients. They concluded the following :1. On average, nonextraction patients had less facial changes as a result of
orthodontic treatment than a similar group of extraction patients; the magnitude of
the mean difference between extraction and nonextraction patients being
approximately 6 o in the nasolabial angle, 1 to 2 mm in upper lip protrusion, and 2
to 3 mm in lower lip protrusion.
2. Although average changes are less in nonextraction patients, the range of
individual changes in facial profile is almost as great for nonextraction cases as for
extraction cases. Furthermore, the range of response by individual patients is very
large; up to 60 o for angular measurements of lip position and 11 to 13 mm for
liner measurements of lip protrusion.
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3. It would seem that nonextraction cases should offer much less of an opportunity
for the clinician to alter the profile. It has been vigorously argued ( and assumed )
by some that nonextraction treatment is the solution to undesirable facial changes
( and particularly the dished- in look.).
4. The facial appearance should be judged on an overall basis rather than as a
series of individual features. The difference in the nasolabial angel versus the
protrusion of the lips illustrates that improvements in one measurement may result
in unfavorable changes in another measurement. The consequences of esthetics
cannot be judged by comparing numbers
3 - TMJ
First premolar extraction is considered by many to be an etiologic factor in
TMJ disorders.
Farrar and McCarthy, among others, believed that extraction of premolars
during the course of orthodontic therapy are considered to be a predisposing factor
in TMJ anterior disk displacement and TMJ disordered for the following reasons :1. Extraction of premolars permits the posterior teeth to move forward
resulting in a decrease in the vertical dimension of occlusion. The mandible is then
allowed to overclose, and the muscles of mastication become foreshortened. As
result, TMJ problems are likely go occur. Although this theory is popular,
particularly among general practitioners, no controlled study has published results
supporting this hypothesis.
2. Another theory that has been proposed is that first premolar extractions lead
to overretraction of the anterior teeth, particularly the maxillary anterior. This
overretraction of anterior teeth is thought to displace the mandible an the condyles
posteriorly. Posterior condylar displacement has long been associated with TMJ
disorders. As with the previous hypothesis, this theory has not been substantiated
by research.
Kundinge, among others, were measured the anterior and posterior condylar
space through the corrected axial tomogram. They had shown that,either in their
cross sectional or longitudinal studies, the extraction of premolars did not affect the
so called condylar positions of extraction treated subjects. Concerning the forward
rotation of the mandible, as an etiologic factor in the TMJ disorders, it was
mentioned previously.
Reilly et al., examined clinically the TMJ in extraction orthodontic patient
before and after orthodontic treatment for the presence of the sings or symptoms of
TMJ disorders. As a result of their study, they support the hypothesis that
orthodontic treatment is not costive of TMJ disorders.
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- In class III cases, the extraction of upper first premolars should be avoided .
Extraction of the mandibular first molar in these cases, in the absence of the
crowding, leads to presence of residual spacing, as a result of the tongue action on
the lower incisors and the growth of the mandible.
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Lower incisorCanut
* Indication :1. Anomalies in the number of anterior teeth.
2. Tooth size anomalies.
3. Ectopic eruption of incisors .
4. Moderate class III malocclusions.
* Clinical implication :1. An accentuated overjet is contraindication to removed of single lower
incisors.
2. Removal of an incisors cause the canine to displace mesially.
3. Diagnostic setup of final occlusal status must be evaluated.
4. In certain cases, and particularly among adults, the space either fails to close
or else opens up with ease; visible diastema thus results in an area of
considerable aesthetic and periodontal importance.
* Advantages :One way of preventing relapse is to extract an incisor with extreme
malpositioning, which moreover limits the sometimes unnecessary movement of
many teeth; correction thus becomes more circumscribed to a specific dentition
zone. The loss of gingival tissue of the disappearance of the external alveolar
lamina constitutes an additional indication for extraction of the affected incisor.
Compensating Extraction
When one permanent teeth are lost early or are congenitally missing in one
side, the remaining teeth may move toward the extraction space and sometimes the
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anterior teeth may across the midline with the subsequent asymmetry. To avoid
this, a balanced extraction should be made in which teeth in the other side as
removed. It is not necessarily to extract the same tooth in the other side.
The following general principles are applied when considering compensation
extractions :
(1) In a class I malocclusion where there is crowding but a normal overbite
and overjet, unavoidable extraction or missing teeth in one buccal segment, a
compensating extraction should be made in the opposing arch to reduce the
movement of the center line and to maintain the overbite.
(2)Where the overbite is excessive and there is a class II tendency,
unavoidable extractions or missing teeth in the lower arch will require a
compensating extraction in the upper arch but not vice versa.
(3)Where there is a class II tendency, unavoidable extractions or missing teeth
in the upper arch require compensating extractions in the lower arch but not vice
versa.
The aim of compensating extraction is to avoid lateral asymmetry, midline
and to establish normal occlusion.
References
Bernstein, L . : Edward H . Angle versus Clavin S . Case : Extraction versus nonextraction. Part I . Historical
revisionism. Am. J. Orthod. Dentofac . Orthop. 102 : 464 - 470 , 1992.
Beattie, J. R. ,Paquette, D. E and Johnston, L. E. : The functional impact of extraction and nonextraction
treatment :A long term comparison in patients with borderline, equally susceptible Class II malocclusions. Am.
J. Orthod. Dentofac . Orthop. 105 :444-449, 1994.
Canut, J. A. : Mandibular incisor extraction : indications and long-term evaluation. European Journal of
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Daugaard-Jensen, L. : Extraction of first molars in discrepancy cases. Am. J. Orthod. 64 : 115 -136 , 1973.
Drobocky, O. B. and Smith, R. J. : Changes in facial profile during orthodontic treatment with extraction of four
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459 - 460 , 1978.
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Orthod. 48 : 132-140 ,1978. Quoted from Yamaguchi Y. and Nanda R. S. : The effect of extraction and
nonextraction treatment on the mandibular position. Am. J. Orthod. Dentofac . Orthop. 100 : 443-452 , 1991.
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34:
75-93 , 1964. Quoted from Chua, A. , Lim, J. Y. S. and Lubit, E. C. : The effects of extraction versus nonextracton
orthodontic treatment on the growth of the lower anterior face height. Am. J. Orthod. Dentofac . Orthop. 104 :
361 - 369 , 1993.
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- 24, 1994.
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incisors. Am. J. Orthod. Dentofac . Orthop. 91: 385-394, 1987.
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Am. J. Orthod. Dentofac . Orthop. 100 : 443-452 , 1991.
Young, T. M. and Smith, R. J. : Effects of orthodontics on the facial profile: A comparison of changes during
nonextraction and four premolar extraction treatment. Am. J. Orthod. Dentofac . Orthop. 103 : 452 -458 , 1993
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