serial extraction

Pedodontics

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

2. CONTENT Definition History Principles Rationale Objectives Indications Contraindications Diagnosis and treatment planning Procedure Techniques – Dewel , N ance , 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 3 rd 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 3 rd 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 3 rd 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

11. CONTRAINDICATIONS

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 3 rd 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 & 2 nd molars Intercuspation of 1 st molars

16. TECHNIQUE AND STAGES IN SERIAL EXTRACTION THERAPY T iming and sequencing for extracting primary and permanent teeth  key to success. S erial 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 1 ST 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 4-10 Month

25. DEWEL METHOD (CD4)-1978 MODIFIED DEWEL

26. NANCE METHOD-D4C

27. MOYER’S METHOD-BCD4

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 C lass 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

30. GROUP B – Anterior discrepancy : A lveolodental protrusion

31. MIDDLE DISCREPANCY : IMPACTED CANINE

32. GROUP D- ENUCLEATION IN THE MANDIBLE

33. Group E : Enucleation in the maxilla and mandible

34. Group F– A lternative to enucleation

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

37. Group B- Middle discrepancy : I mpacted maxillary canine

38. Group C – P osterior discrepancy : Ectopic eruption in the maxilla

39. Group D- anterior discrepancy : maxillary protrusion , mandibular incisor crowdi n g

40. Group E – Middle discrepancy : Maxillary and mandibular canine and premolar crowding

41. Posterior discrepancy : Maxillary and mandibular molar crowding

42. GRABER 1971

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