2/5/2015

1

Extraction in the

Mixed Dentition ─

1

A Reasonable

Alternative for

Selected Patients?

2

I declare that neither I, nor any member of my

family, has a financial arrangement or affiliation

with any corporate organization which offers

financial support or grant monies for this

continuing education presentation, nor do I have a

financial interest in any commercial product(s) or

services I will discuss in this presentation.

3 4

“War of Roses” Tennessee

Governor's Race 1886

The Taylor Brothers

5 N. Nash

2/5/2015

2

N. Nash N. Nash

N. Nash N. Nash

11

N. Nash Pretreatment FMIA 70

FMA 20

IMPA 90

SNA 83

SNB 80

ANB 3

AO-BO 4mm

OCC 0

Z 90

Options

1.Space Management

2.Expansion – Arch

Development

3.Extraction in the Mixed

Dentition

12

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13

But ─ Before Options Are

Considered ─

How Much Space

Is Needed?

How Much Space is Needed?

Space Available

4mm

4mm

20.0mm 18.5mm

Totals

Maxillary Arch

Space Required 16.5mm

Space Available 8.0mm

Deficit 8.5mm

16

Mandibular Arch

Space Required 46.1mm

Space Available 38.5mm

Deficit 7.6mm

Option

17

Space

Management

Maxillary Arch ─ Must

Have 8.5mm

18

No Space

to Manage

4mm

4mm

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Space Management Mandibular Arch

19

Left side ─

Yes

Right side

20.0mm 18.5mm

- 4.6mm

? 20

Space Management

Plus

Interproximal

Reduction?

21

Space Needed

Interproximal

Reduction???

Maxillary Arch ─ 8mm

Mandibular Arch ─ 7.6mm

Option

Make Space for

the Teeth

22

N. Nash

Space Space

24

Make Space for the Teeth

Expansion ─ Arch

Development

Yes!

Does Our Science

Need to be Consulted?

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5

What Happens

With No Treatment?

25 26

Sinclair and Little (1983)

• Sinclair and Little (1983) Reported on a

Sample of 65 Subjects With Normal

Occlusions For Changes in the Dental

Arch From the Mixed Dentition, to Early

Permanent Dentition, and into Early

Adulthood.

• Arch Length Decreased From the Mixed

Dentition into Early Adulthood While

Incisor Irregularity Increased From 13 to

20 Years of Age.

27

Richardson (1999)

• Evaluated the Changes in Alignment in the

Untreated Lower Arch at Various

Developmental Stages: 7 to 15 Years, 13 to

18 Years, 18 to 21 Years, and 18 to 50

Years.

• After Evaluation of the Dental Arch at

Various Developmental Stages, Richardson

(1999) Concluded That the Greatest

Increase in Amount of Lower Incisor

Crowding Occurs Between the Ages of 13

and 18 Years of Age (= 2.3 mm).

28

Yes!

Does Arch Length Inevitably Decrease

From Mixed Dentition to Adult Dentition? Barrow & White, AJO 1952

Brown, et al, Act. O Scand 1951

Little, et al, AJO 1990

Lundstrom, Dent Pract 1969

Moyers, HandBK of Ortho 1985

Moorees, Harv Univ Press 1959

Nance, AJO 1947

Sinclair, et al, AJO 1983

Sillman, AJO 1964

What Happens

With Treatment?

29 30

When Mandibular Incisors Are Proclined

During Treatment, Do They Tend to

Upright? Nance, AJO 1947

Mills, Brit Ortho Jrn 1966

Litowitz, Angle Ortho July-Oct 1948

Cole, Angle Ortho July-Oct

Hixon, AJO 42:898, 1956

Hixon, Angle Ortho 42:200, 1972

Weinstein, Angle Ortho 33: 1, 1963

Miller, U of Oregon Thesis 1971

Boley, UMKC Thesis 1966

Yes!

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31

Do Expanded Mandibular Canines

Typically Constrict After the Removal of

Retention? Bishara, et al, AJO1989

Glenn, et al, AJO 1987

Little, et al, AJO 1981

McCauley, AJO 1944

Riedel, Angle Ortho 1966

Sandusky, Thesis 1983

Shapiro, AJO 1974

Sondhi, et al, AJO 1980

Steadman, Angle Ortho 1961

Strang, Angle Ortho 1949, 1952

Yes!

• Arch form tended to return toward the

pretreatment shape after retention.

• Greater the treatment change, the greater the

tendency for postretention change.

• However, individual variation was considerable.

• Patient's pretreatment arch form appeared to be

the best guide to future arch form stability.

32

de la Cruz A, Sampson P, Little RM, Artun J, Shapiro PA.

Long-term Changes In Arch Form After Orthodontic

Treatment And Retention. Am J Orthod Dentofacial Orthop. 1995 May;

107(5):518-30.

Over expansion was found to be a

factor in mandibular incisor

relapse.

33

Kahl-Nieke B, Fischbach H, Schwarze CW. Post-retention

Crowding And Incisor Irregularity: A Long-term Follow-up

Evaluation Of Stability And Relapse. Orthod. 1995

Aug;22(3):249-57.

El-Mangoury NH. Orthodontic Relapse In Subjects With Varying

Degrees Of Anteroposterior And Vertical Dysplasia. AJO/DO, Vol. 75,

#5, May 1979, pp 548-561.

• In both the- stable and the relapse groups, the mandibular intercanine width decreased postretention. This decrease was associated more with the relapse group than with the stable group.

• The mandibular intercanine width tended to relapse toward its original pretreatment value. This suggests that, at the end of active treatment, the mandibular intercanine width should be maintained as originally presented.

• There was no significant interaction between orthodontic relapse (or stability) and whether or not extraction was included as a part of the mechanotherapy.

34

35

The Washington Studies Should

Not Be Interpreted to Mean That

The Position of the Teeth

Does Not Matter

36

• Twenty-two of the 30 cases (73%) demonstrated clinically

unsatisfactory mandibular anterior alignment postretention.

• Intercanine width and arch length decreased in 29 of the 30

cases by the postretention stage.

Little RM, Riedel RA, Enqst ED. Serial extraction of first premolars-

postretention evaluation of stability and relapse. Angle Orthod. 1990

Winter;60(4):255-62.

• At post-retention, 9.0% had irregularity index values of 6.5

mm or more and 47.4% had values equal to 3.5 mm or less.

• Treatment increase of intercanine width and post-retention

decrease of intercanine width and arch length were

associated with relapse.

Artun J, Garol JD, Little RM. Long-term stability of mandibular incisors

following successful treatment of Class II, Division 1, malocclusions.

Angle Orthod. 1996;66(3):229-38.

2/5/2015

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37

There Are No Studies of

Patients Treated With

Expansion Who Have Been

Recalled Twenty Five Years

After Treatment

So — What Should We

Do? 38

Treatment Plan With

Strang, Nance, Tweed,

Merrifield, Mangoury,

Blake & Bibby, & Boley!

39

Strang, R.H.W. “The Fallacy Of Denture

Expansion As A Treatment Procedure.”

The Angle Orthodontist, 1949: 49: 12 -

17.

Nance, H. “The Limitations of Orthodontic Treatment”, Am J of Ortho & Oral Surg 33:253-301, 1947.

40

Tweed, CH. “Indication for the

Extraction of Teeth in Orthodontic

Procedures,” AM J of Ortho Oral Surg

30:405, 1944.

Tweed, CH. “A Philosophy of Orthodontic Treatment”, Am J of Ortho & Oral Surg 31:74, 1945.

41

Merrifield, LL. “Differential

Diagnosis,” Seminars in

Orthodontics #2, 241, 1996.

Merrifield, LL. “The Dimension

of the Denture: Back to the

Basics,” AJO/DO Vol106:535,

1994.

42

Boley JC, Mark JA, Sachdeva RC, Buschang PH.

"Long-term stability of Class I premolar extraction

treatment." Am J Orthod Dentofacial Orthop. 2003

Sep;124(3):277-87.

Paquette DE, Beattie JR, Johnston LE Jr. "A long-

term comparison of nonextraction and premolar

extraction edgewise therapy in "borderline" Class II

patients." Am J Orthod Dentofacial Orthop. 1992

Jul;102(1):1-14.

2/5/2015

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43

Does Expansion

Compromise Facial

Esthetics?

The Face ─

44

Many Times It

Does

It Can!

Expansion Can Harm

Facial Esthetics

45 46

Is There An

ANTERIOR LIMIT

OF THE DENTITION?

47

Merrifield’s Z Angle

48

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49

STEINER

50

Tweed, CH. “The Frankfort Mandibular Incisor Angle (FMIA) In Orthodontic Diagnosis, Treatment Planning and Prognosis”, Am J of Ortho & Oral Surg 24:121, 1954.

Burrow, SJ. “Smile Esthetics After Orthodontic Treatment With and Without Extraction of Four First Premolars,” Seminars in Orthod, Vol 18, #3, Sept 2012 pp 201-209.

Expansion – Arch Development

Maxillary Arch ─ Must have 8.5mm

51

4mm

4mm

52

Now ─

Some Specific

Questions

53

Can We

Expand the

Maxillary Arch?

54

─ Yes ─

But Should We?

2/5/2015

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55

Adkins MD, Nanda RS,

Currier GF. Arch Perimeter

Changes on Rapid Palatal

Expansion. Am J Orthod

Dentofacial Orthop. March

1990;97(3);194-199.

56

1mm of Lateral Expansion

Expansion Required ≈ 12mm

Yields .66 mm of Arch

Perimeter Gain

57

Schiffman PH, Tuncay OC. Maxillary

expansion: a meta analysis. Clin Ortho Res,

2001 May;4(2); 86-96.

The mean expansion after adjustment according to

the principles of meta analysis was 6.00 mm with a

standard deviation of 1.29 mm. Of the 6-mm average,

4.89 mm was retained while wearing retainers…

Finally, in the long-term post-retention study period

only 2.4 mm of the residual expansion was reported

to have remained. This 2.4 mm of expansion

remaining after more than a year or more of post-

retention period was no greater than what has been

documented as normal growth. 58

Gianelly AA. Rapid Palatal

Expansion in the Absence of

Crossbites: Added Value?

Am J Orthod Dentofacial

Orthop. October 2003;

124(4);362-365.

59

If We Expand the

Maxillary Dentition in the

Absence of Crossbite ─

We MUST EXPAND

the Mandibular

Dentition 60

Gianelly – “One conclusion is

that the use of the maxillary

arch as the template for the

mandibular arch might

jeopardize the stability of the

mandibular arch by expanding

it in areas that are known to be

unstable.”

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61

Is It Prudent to

Expand the

Mandibular

Dentition? 62

Burke SP, Silveira AM,

Goldsmith LJ, Yancey JM, Van

Stewart A, Scarfe WC. “A

Meta-Analysis of Mandibular

Intercanine Width in Treatment

and Postretention", Angle

Ortho. February 1998; 68:53-

60.

63

Burke et al Performed a

Meta-Analysis of 26 Articles –

Evaluated 1233 Patients

Conclusion: Most Prudent

Course Is to Maintain the

Original Intercanine Dimension

Conclusion – Lateral Maxillary

Expansion is Probably Not a

Good Solution for Our Patient

64

4mm

4mm

65

Lateral Mandibular

Expansion is Not a

Prudent Option

20.0mm 18.5mm

66

What About

Moving the Teeth

Distally?

Not Laterally?

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67

Is There a

Posterior Limit of

the Dentition?

Yes!! 68

THE POSTERIOR LIMIT OF

THE DENTITION

69

A Modern

“Widget”

70

This Patient is

17 years old.

The second

molars are

impacted due to

distalization

mechanics.

71

We Can Easily Push the

Maxillary Teeth Distally

But What About

the Mandibular

Teeth?

AJO/DO Vol 146, No 2

72

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73 74

What About

Maintaining the

Position of the

Mandibular

Posterior Teeth?

75

K. Cox

76

K. Cox

14 Months into Treatment

77

K. Cox

AJO/DO Vol 141, No 2

78

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79

Rebecca Lash Rubin, Tiziano Baccetti, and

James A. McNamara, Jr

80

300 Patients ─ Four Groups

– Schwarz

– Lingual holding Arch

– Combination of Schwarz

& Holding Arch

– Control

81

Findings / Conclusions

Orthodontic Appliances

Intended to Maintain Arch

Perimeter in the Mixed

Dentition Increase the

Probability of Eruption

Disturbances of the

Mandibular Second Molars. 82

Findings / Conclusions

“All 3 Treatment Groups

Had a Higher Incidence

of Mandibular Second

Molar Eruption Difficulty

When Compared with the

Controls.”

83

The Bottom Line

on Arch

Development

84

“Most Often the Arch Length Gain

Occurs by Lower Incisor

Proclination and/or An Increase in

Intercanine Width, Both Being

NOTORIOUSLY Unstable.”

David Kennedy

Early Treatment Options

PCSO Bulletin – Summer 2010

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85 86

87

Bowman SJ. “Pulsus a

Mortuus Equus”

(Beating a Dead Horse)

Seminars in Orthodontics, Vol 20,

#1, 2014, pp 36-45.

Arguments About Age – Appropriate

Arch Length Alternatives. 88

Lysle E. Johnston Jr

MORE Bone or

LESS Teeth!

That is the Choice!

Peck, Sheldon. “The Current Fashion of Nonextraction Dental

Arch Expansion in Orthodontics: A Critique” Seminars in

Orthodontics, Vol 18, #2, June 2012, pp 126-127.

89

Today, conscientious orthodontists are

being challenged by commercially

marketed appliance systems that promise

easy solutions and are based on

nonextraction dental arch expansion. This

is a throwback to orthodontic methods

advocated a century ago, long before the

evidence-based era of orthodontics,

radiography, and periodontology. 90

Arch Development

Little RM, Riedel RA, Stein A.

Mandibular Arch Length Increase During

Mixed Dentition: Postretention

Evaluation of Stability and Relapse. Am

J Ortho Dentofacial Orthop. May

1990:97 (5):393-404.

It is a FAILURE 87%

of the Time

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91

“…this strategy shows

greater relapse than other

samples we have

collected.”

Little RM, Riedel RA, Stein A. Mandibular arch length

increase during the mixed dentition: postretention evaluation

of stability and relapse. Am J Orthod Dentofacial Orthop.

1990; 97(5);393-404. 92

Am J Orthod Dentofacial Orthop

2006; 130:202-13

93 94

95

Mandibular Arch

Perimeter

Decreased in Both

Treated Samples What is the Best

Choice for Natalie?

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17

Options

1.Space Management

2.Expansion – Arch

Development

3.Extraction in the Mixed

Dentition 97 98

Option

Extraction in the

Mixed Dentition

99

Age 6

100

..."It is better to have one or two

teeth less in each jaw, provided it

can be compensated by a suitable

arrangement, than to have the

entire set of teeth poorly arranged

and ill at ease…”

Bunon R. Essay sur las maladies des dents. Conference. In:

Paris; 1743.

101

“By sacrificing the (deciduous)

canine teeth to the incisors and

the small molars (premolars) to the

(permanent) canines it will be

possible to leave free space to

make an attractive arrangement."

Bunon R. Essay sur las maladies des dents. Conference. In:

Paris; 1743.

102

In 1896, J.F. Colyer advocated extractions “to

gain room for the crowns and roots, to

decrease mechanical treatment and in many

cases to abolish it as well as to relieve the

pressure on the teeth and prevent caries, to

improve the bite, and finally to have the teeth

naturally assuming a better position”.

Colyer J. Discussion on the early treatment of crowded

mouths. Odont Soc Trans. 1896;28(2):215–33.

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103

Kjellgren B. Serial Extraction as a

Corrective Procedure in Dental

Orthopedic Therapy, Eur. Orthod.

Soc. Trans p134, 1947–1948.

Special Knowledge is

Required

104

The phrase Serial

Extraction has resulted in

the poorly planned

removal of teeth by people

who do not have the

necessary knowledge. Jack Dale

105

Hotz’s Guidance of Eruption

implies that knowledge of

growth and development is

necessary to direct the teeth

as they erupt.

Hotz R. Guidance of eruption

versus serial extraction, Am J

Orthod 58:1, 1970.

106

“Guidance of Occlusion –

an even better term

because occlusion is the

final destination of a tooth

that is erupting.” ─ Jack Dale

107 108

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This chapter is THE State of

the Art work on extraction of

teeth in the mixed dentition.

• Fabulous Illustrations

• Impeccably Referenced

• Meticulous Explanations

109

This chapter is a

MUST reference for

every clinical

orthodontist.

110

111

Graber TM. Serial extraction: a continuous

diagnostic and decisional process. Am J Orthod.

1971;60:541-75.

Heath J. The interception of

malocclusion by planned serial

extraction. New Zealand J.

1953;49:77-88.

112

Dewel BF. Serial extraction; its

limitations and contraindications.

Ariz Dent J. 1968;14(6):14-30.

Dewel BF. Prerequisites in serial

extraction. Am J Orthod. 1969;55:533-9.

113

Dewel BF. Editorial. A question of

terminology: serial extraction or

guidance of eruption. Am J Orthod.

1970;58:78-9.

Dewel BF. Precautions in serial

extraction. Am J Orthod. 1971;60:615-8.

Lloyd ZB. Serial extraction as a

treatment procedure. Am J Orthod.

1956;42:728-39.

114

Tweed CH. Treatment planning and

therapy in the mixed dentition. Am J

Orthod. 1963;49:881-906.

Jacobs J. Cephalometric and clinical

evaluation of class I discrepancy cases

treated by serial extraction. Am J Orthod.

1965;51:401-11.

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Dale JG, Brandt S. Dr. Jack G. Dale on

serial extraction. J Clin Orthod.

1976;10(1):44-60.

115

Dale JG, Brandt S. Dr. Jack G. Dale on

serial extraction. 2. J Clin Orthod.

1976;10(2):116-36.

Dale JG, Brandt S. Dr. Jack G. Dale on

serial extraction. 3. J Clin Orthod.

1976;10(3):196-217.

Proffit WR. The timing of

early treatment: an

overview. AM J Orthod

Dentofac Orthop. 2006;

129:47-49.

116

117

Prior to ANY

Extraction Decision

Complete Records

Treatment Plan

A Careful Analysis

• Face

• Skeletal Pattern

• Teeth

118

119

Mixed dentition

extraction procedures

seem to work best when

the face has balance or is

at best, mildly protruded.

The Face The Face

Mixed dentition

extractions are generally

contraindicated in a

convex or concave face.

120

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The Face

121

The Skeletal Pattern

Vertical

Dimension

should be within

NORMAL Limits 122

The Skeletal Pattern

Mixed dentition

extractions are generally

contraindicated in patients

with hyperdivergent or

hypodivergent skeletal

patterns. 123 124

The Skeletal Pattern

The anteroposterior relationship

of the maxilla to the mandible

should be “normal.” If the

mandible is either retrognathic

or prognathic, mixed dentition

extractions are generally not

indicated. 125

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What About

Mixed Dentition

Extraction in the

Class II Dental

Relationship? 127

Proceed with

Caution!

128

Be Prepared to

1) Correct the Class II

Molar Relationship with

Mandibular Extraction

2) Treat to a Class I

Canine / Class II Molar 129 130

HB Byers

HB

Bye

rs

131 132

HB Byers

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HB Byers 133 134

HB

Bye

rs

135

HB Byers 136

Dugoni SA. Comprehensive mixed dentition

treatment. Am J Orthod Dentofac Orthop. 1998;113,

p75–84.

Dugoni SA, Aubert M, Baumrind S. Differential

diagnosis and treatment planning for early mixed

dentition malocclusions. Am J Orthod Dentofac

Orthop. 2006; 129, Issue 4, S80–S81.

The Dentition The Clinician MUST ascertain

the space required and the

space available.

137

And Other Factors?

Arch Length/Tooth Size Deficiency

• How much crowding would indicate that

extractions of permanent teeth may be

indicated?

• 7mm or more of crowding was an

indication (Ringenberg)

• 10 mm or more of crowding (Proffitt)

138

Ringenberg Q. Serial extraction: Stop, look, and be certain.

Am J Orthod. 1964;50:327–36.

Proffit WR. The timing of early treatment: an overview. Am J

Orthod Dentofac Orthop. 2006;129:47–49.

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The Dentition There are several methods that

can be used to predict the

space needed and the space

required.

Whatever the method of choice,

139

USE IT!

Hixon EH, Oldfather RE.

Estimation of the sizes of

unerupted cuspid and bicuspid

teeth, Angle Ortho 28:236, 1958.

Huckaba GW. Arch size analysis

and tooth size prediction. Dent

Clin North Am 431, 1964. 140

Gardner RA. “A Comparison of

Four Methods of Predicting

Arch Length” Am J Orthod,

1979, 75(4) 387-398.

141

“Tanaka and Johnston Analysis

seems to be the one most

frequently used since it is a pure

calculation.”

The “Dale” Method

• Space Available vs Space Required

• Curve of Spee Correction

• Evaluation of Protrusion

(Its Correction Requires Space)

• Posterior Dentition Area Evaluation

Jack Dale, Chapter 11 142

Therefore, a THOROUGH Study of:

The Face

The Skeletal Pattern

The Dentition

MUST Be Done in Order to

Formulate a Mixed Dentition

Extraction Treatment Plan. 143 144

Age 9

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145 146

Four First Premolars Were Removed

During the Mixed Dentition.

147

Age 11

What is the Best

Choice for Natalie?

Four First

Premolars and

Mandibular

Deciduous Teeth

Were Removed 149

N. Nash

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N. Nash N. Nash

N. Nash N. Nash

N. Nash N. Nash

2/5/2015

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N. Nash N. Nash

N. Nash Pretreatment N. Nash Progress FMIA 70

FMA 20

IMPA 90

SNA 83

SNB 80

ANB 3

AO-BO 4mm

OCC 0

Z 90

FMIA 70

FMA 20

IMPA 90

SNA 83

SNB 80

ANB 3

AO-BO 4mm

OCC 0

Z 90

N. Nash

Pretreatment

Progress 160

N. Nash N. Nash

162

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N. Nash 163

N. Nash 164

N. Nash 165

N. Nash 166

N. Nash 167

N. Nash 168

2/5/2015

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N. Nash N. Nash

N. Nash Pretreatment N. Nash Posttreatment FMIA 70

FMA 20

IMPA 90

SNA 83

SNB 80

ANB 3

AO-BO 4mm

OCC 0

Z 90

FMIA 69

FMA 19

IMPA 92

SNA 83

SNB 80

ANB 3

AO-BO 0mm

OCC 0

Z 90

N. Nash

Pretreatment

Progress

Posttreatment 172

173

N. Nash

174

N. Nash

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N. Nash

176

Is Mixed Dentition

Extraction Expedient

For the Majority of

Crowded Class I

Dentitions?

NO!!!!

M. Denman 177

M. Denman 178

M. Denman 179

FMIA 77

FMA 21

IMPA 82

SNA 78

SNB 78

ANB 0

AO-BO -4mm

OCC 10

Z 79

UL 16mm

TC 14mm

PFH 43mm

AFH 60mm

INDEX .70

M. Denman Pretreatment

180

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M. Denman 181

M. Denman 182

M. Denman 183

M. Denman 184

M. Denman 185

M. Denman Pretreatment

FMIA 77

FMA 21

IMPA 82

SNA 78

SNB 78

ANB 0

AO-BO -4mm

OCC 10

Z 79

UL 16mm

TC 14mm

PFH 43mm

AFH 60mm

INDEX .70 186

FMIA 77

FMA 21

IMPA 82

SNA 78

SNB 79

ANB -1

AO-BO -4mm

OCC 8

Z 80

UL 16mm

TC 14mm

PFH 47mm

AFH 62mm

INDEX .75

M. Denman Recall

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Pretreatment

Posttreatment

Recall

M. Denman

187 M. Denman

188

M. Denman 189

190

191

192

Extraction of Teeth in the

Mixed Dentition ─

A Reasonable Option for

Selected Patients?

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Two Key Words

•Reasonable

•Selected

193

In My Caveman Practice ─

Less Than 10%!! of the

Patients Between the Ages

of 8 and 12 Have Mixed

Dentition Extractions

194

195

If It Is

Reasonable ─ And If

the Patient Has the

Criteria

IT IS A GREAT PATIENT

SERVICE! 196

Age 15

197

Fifty-Eight Years After

Mixed Dentition

Extraction

No Other Treatment 198

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199 200

201

Thank You!

Age 68