Serial extraction is the planned

extraction Extraction may refer to: Science and technology Biology and medicine * Comedo extraction, a method of acne treatment * Dental extraction, the surgical removal of a tooth from the mouth Computing and information science * Data extraction, the pro ...

of certain

deciduous teeth Deciduous teeth or primary teeth, also informally known as baby teeth, milk teeth, or temporary teeth,Illustrated Dental Embryology, Histology, and Anatomy, Bath-Balogh and Fehrenbach, Elsevier, 2011, page 255 are the first set of teeth in the ...

and specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into a more favorable position.

History

In 1929, Kjellgren of

Sweden Sweden, formally the Kingdom of Sweden,The United Nations Group of Experts on Geographical Names states that the country's formal name is the Kingdom of SwedenUNGEGN World Geographical Names, Sweden./ref> is a Nordic country located on ...

used the term "serial extraction" for the first time. In the 1940s the technique was popularised in the

United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...

Hayes Nance Hayes Nance (August 14, 1893 - April 3, 1964) was an American orthodontist known for his contributions to topics related to mixed dentition. Nance is known for developing serial extraction in United States, as well as pioneering the development ...

as “planned and progressive extraction”. Nance is known as the Father of serial extraction in the United States. In 1970 Hotz in Switzerland called it active "supervision of teeth by extraction."

Procedure

There is no fixed technique to be followed while carrying out serial extractions. Careful

diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...

and continuous re-evaluation during the course of treatment is mandatory to achieve required results. However based on the usual eruption sequence of teeth, deciduous

canines Canine may refer to: Zoology and anatomy * a dog-like Canid animal in the subfamily Caninae ** ''Canis'', a genus including dogs, wolves, coyotes, and jackals ** Dog, the domestic dog * Canine tooth, in mammalian oral anatomy People with the surn ...

are extracted at the age of 8–9 years to create space for proper alignment of

incisors Incisors (from Latin ''incidere'', "to cut") are the front teeth present in most mammals. They are located in the premaxilla above and on the mandible below. Humans have a total of eight (two on each side, top and bottom). Opossums have 18, wh ...

, followed by extraction of deciduous first molars a year later so that the eruption of first

premolars The premolars, also called premolar teeth, or bicuspids, are transitional teeth located between the canine and molar teeth. In humans, there are two premolars per quadrant in the permanent set of teeth, making eight premolars total in the mouth ...

is accelerated and lastly extraction of the erupting first premolars to give space for the alignment of permanent canines. In some cases a modified technique is followed in which the first premolars are enucleated at the time of extraction of the deciduous first molar. This modification is frequently necessary in the mandibular arch where the canines often erupt before the first premolars.

Selection of suitable extraction procedure

Extracting the primary canines only – it produces rapid self-improvement in incisor crowding and alignment intercepting the development of lingual

crossbite Crossbite is a form of malocclusion where a tooth (or teeth) has a more buccal or lingual position (that is, the tooth is either closer to the cheek or to the tongue) than its corresponding antagonist tooth in the upper or lower dental arch. In o ...

of the lateral incisors. Extracting the first primary molars only – this approach produces the earlier eruption of first premolars but reduces the rapidity and amount of incisor alignment. This is the result of retention of primary canines. Extracting both primary canines and first molars – this is a compromise between rapid improvement in incisor alignment and the desired early eruption of first premolars. In some cases this sequence results in simultaneous eruption of canines and first premolar, which may cause an increased distal translation of the permanent canines and possible impaction of first premolars. Enucleation of first premolar buds – it is advocated when first premolar eruption is behind that of canines and second premolars. This allows maximal distal translation of the erupting canines.it is rarely indicated in the

maxilla The maxilla (plural: ''maxillae'' ) in vertebrates is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The t ...

ry arch.

Indications

*In cases of class 1

malocclusion In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855-1930), ...

that show harmony between skeletal and muscular system *Cases which present with arch length deficiency – indicated by the presence of one or more of the following: **Absence of physiologic spacing **Unilateral or bilateral premature loss of deciduous canines with

midline In typography, the mean line is the imaginary line at the top of the x-height. upright 2.0, alt=A diagram showing the line terms used in typography Round glyphs will tend to break ( overshoot) the mean line slightly in many typefaces, since thi ...

shift **Malpositioned or impacted lateral incisors that erupt palatally out of the arch **Markedly irregular or crowded maxillary and mandibular anteriors **Localized

gingival recession Gingival recession, also known as receding gums, is the exposure in the roots of the teeth caused by a loss of gum tissue and/or retraction of the gingival margin from the crown of the teeth.Ankylosis Ankylosis is a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease. The rigidity may be complete or partial and may be due to inflammation of the tendinous or muscular ...

of one or more teeth *Cases with insufficient growth to overcome the tooth material – basal bone discrepancy. *Patients with straight profile and pleasing appearance.

Contraindications

*Class 2 and class 3 malocclusion with skeletal abnormalities. *Patients with adequate spacing in dentition *Cases of

anodontia Anodontia is a rare genetic disorder characterized by the congenital absence of all primary or permanent teeth. It is divided into two subsections, complete absence of teeth or only some absence of teeth. It is associated with the group of skin ...

oligodontia Hypodontia is defined as the developmental absence of one or more teeth excluding the third molars. It is one of the most common dental anomalies, and can have a negative impact on function, and also appearance. It rarely occurs in primary teet ...

*Patients with

open bite Open bite is a type of orthodontic malocclusion which has been estimated to occur in 0.6% of the people in the United States. This type of malocclusion has no vertical overlap or contact between the anterior incisors. The term "open bite" was coine ...

and

deep bite In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855-1930), ...

*In cases of midline

diastema A diastema (plural diastemata, from Greek διάστημα, space) is a space or gap between two teeth. Many species of mammals have diastemata as a normal feature, most commonly between the incisors and molars. More colloquially, the condition ...

*Class 1 malocclusion with minimal space deficiency *Unerupted malformed teeth e.g. dilacerations *Extensive

caries Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicatio ...

or heavily filled first permanent

molars The molars or molar teeth are large, flat teeth at the back of the mouth. They are more developed in mammals. They are used primarily to grind food during chewing. The name ''molar'' derives from Latin, ''molaris dens'', meaning "millstone to ...

*Mild disproportion between arch length and tooth material that can be treated by proximal stripping

Advantages

*Treatment is more physiologic *Psychological trauma can be avoided by treatment at an early age *Reduces the duration of fixed orthodontic treatment *Better

oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried out ...

is possible, so reduced risk of

*Health of investing tissues (periodontium and alveolar process) is preserved, therefore reduced alveolar bone loss *Less retention period is indicated *More stable results are achieved *Less potential iatrogenic damage *Normal neuromuscular balance is achieved and maintained

Disadvantages

*There is no single approach that can be universally applied to all patients *Treatment time is prolonged as the treatment is carried out in stages spread over 2–3 years *Patient has a tendency to develop

tongue thrust Tongue thrust (also called reverse swallow or immature swallow) is a pseudo-pathological name of what is either considered a normal adaptive lip seal mechanism, whereby normal nasal breathing or normal swallowing can occur. Or, it is seen as an o ...

, due to creation of extraction spaces that close gradually *

Extraction Extraction may refer to: Science and technology Biology and medicine * Comedo extraction, a method of acne treatment * Dental extraction, the surgical removal of a tooth from the mouth Computing and information science * Data extraction, the pro ...

of posterior teeth may lead to deepening of bite *There is a risk of arch length reduction because of mesial migration of the buccal segment *Minor spaces may exist between canine and second premolar *Axial inclination of the teeth may change at the end of serial extraction

Assessments to be made before contemplation of serial extraction

Intraoral diagnostic assessment

The diagnosis is based on a thorough case history, clinical examination of the patient, photographs, plaster study models, cephalometric radiographs, panoramic and periapical radiographs.

Growth and development analysis

Periodic growth assessment records should be made in all patients where growth is still going on i.e. made until 14 to 16 year old in girls and 18 to 19 year old in boys.

Functional analysis

Checking various functional movements like swallowing, respiration, speech, opening and closing and excursive movements of the mandible and careful palpation of both

temporomandibular joints In anatomy, the temporomandibular joints (TMJ) are the two joints connecting the jawbone to the skull. It is a bilateral synovial articulation between the temporal bone of the skull above and the mandible below; it is from these bones that it ...

is important.

Morphologic assessment

It includes assessment of tooth mass, arch form, arch length, skeletal pattern, skeletal growth potential, orofacial musculature, facial aesthetics, oral habits and hereditary assessment of parents and siblings. The most favorable morphologic factors for serial extraction include class 1 malocclusion, a favorable morphogenetic pattern – one that does not change, a flush terminal plane or a mesial step relationship of the primary second molars, minimum

overjet Overjet is the extent of horizontal ( anterior-posterior) overlap of the maxillary central incisors over the mandibular central incisors. In class II (division I) malocclusion the overjet is increased as the maxillary central incisors are protrud ...

and minimum

overbite Overbite is the extent of vertical ( superior-inferior) overlap of the maxillary central incisors over the mandibular central incisors, measured relative to the incisal ridges. The term overbite does not refer to a specific condition, nor is ...

Space analysis

Assessment of the tooth size – arch length relationship in the mixed dentition determines the presence or absence of any future or existing discrepancy, whether it is crowding or spacing. It involves the prediction of tooth size of the unerupted permanent canines and premolars. A

caliper A caliper (British spelling also calliper, or in plurale tantum sense a pair of calipers) is a device used to measure the dimensions of an object. Many types of calipers permit reading out a measurement on a ruled scale, a dial, or a digital dis ...

or a fine line divider is used to measure the combined width of teeth in each segment using study models. The circumferential measurement is made on the plaster cast from mesial aspect of first molar on one side to the mesial aspect of the first molar on the opposite side, and this measurement is recorded. Combined width of the permanent teeth is taken from intraoral radiographs and compared with the available arch length.

Factors to be considered in space analysis

*A curve of occlusion formula is used to determine the additional space required to flatten the

curve of spee In anatomy, the Curve of Spee (called also von Spee's curve or Spee's curvature) is defined as the curvature of the mandibular occlusal plane beginning at the canine and following the buccal cusps of the posterior teeth, continuing to the terminal ...

. *For every 1 degree of labial or lingual tipping of the mandibular incisors there is 0.8 mm of respective increase or decrease in arch length. *The clinical image of the patient involves the interpretation of that individual’s own data because patients represent multiracial origins and therefore a unified norm is difficult to determine.

Factors to consider during serial extraction

*Serial extraction should be limited essentially to class 1 malocclusion with an initial normal sagittal jaw relationship and normal neuromuscular balance. It is the objective of this treatment to maintain the neuromuscular balance. *With the proper diagnostic assessment skilled timing and careful monitoring, programmed serial extraction procedures are capable of producing extensive amounts of permanent tooth translation. The earlier the first premolars are removed, the greater the distal eruption of the permanent canines. *Too much uprighting of the incisors in the available space can result in too flat a face caused by the dishing in of the anterior segment. The mandibular anterior teeth must be stabilized to prevent excessive lingual tipping. A fixed mandibular arch from the left first permanent molar to the right first permanent molar may be required. *Judicious reproximation disking of primary teeth with no tooth extraction is an occasional option. This decision depends on the careful tooth size-arch length evaluation. *The amount of crowding, the arch length requirements, whether they are symmetric, and the state of health of the investing tissues are factors that continually impact the occlusal guidance program. *Sometimes removal of second premolars or mandibular second premolars and maxillary first premolars may be preferred, depending on facial balance, anchorage requirements, size of tooth and other factors. *Serial extraction is a multi-decisional, time linked process. Annual records such as panoramic radiographs, photographs and study models are essential. *The most common unfavorable sequel of serial extraction is deepening of bite. Uprighting of incisors and early loss of posterior teeth may result in deep bite. A simple palatal bite plate may correct this problem. *Paralleling the roots of teeth contiguous to the extraction sites is usually easy with the autonomous approximation to various degrees before mechanotherapy. *Retention demands are significantly less following serial extraction. However it is better to follow a regular retention regimen for the first six months against possible relapse of rotations and to allow settling of the occlusion. A maxillary Hawley type retainer and a bonded mandibular canine to canine retainer make an efficient retention regimen.

References

{{Reflist, refs= {{cite book, last=Graber, first=T.M., title=Orthodontics principles and practice, year=1996 {{cite book, last1=Graber, first1=T. M., last2=Vanarsdall, first2=R.L., title=Orthodontics: Current Principles and Techniques , year=1994 {{cite book, authorlink1=William Proffit, last1=Proffit, first1=William R., last2=Fields, first2=Henry W., last3=Sarver, first3=David M., title=Contemporary Orthodontics, edition=4th {{cite journal, last=Norman, first=F., date=April 1965, title=Serial Extraction, journal=Angle Orthod, volume=35 , issue=35, pages=149–57, pmid=14280966, url=http://www.angle.org/doi/pdf/10.1043/0003-3219(1965)035%3C0149%3ASE%3E2.0.CO%3B2 {{cite journal, last=Kjellgren, first=B., date=January 1948, title=Serial extraction as a corrective procedure in dental orthopedic therapy, journal=Acta Odontol. Scand., volume=8, issue=1, pages=17–43, pmid=18910774, doi=10.3109/00016354809014459 Dentistry procedures