Serial Extraction
Thus, serial extraction is a planned procedure that demands a minimum of 5 years'
supervision by the dentist of the developing occlusion.
From: Handbook of Pediatric Dentistry (Fourth Edition), 2013
Add to Mendeley Set alert
Orthodontic diagnosis and treatment in
the mixed dentition
John Fricker, ... Julia Dando, in
Handbook of Pediatric Dentistry (Fourth Edition), 2013
Serial extraction
The purpose of serial extraction is to encourage the early
eruption of the first premolars ahead of the permanent
canines and should only be considered where there is an
arch discrepancy of >4 mm. Serial extraction is usually
limited to the upper arch as serial extractions in the lower
arch usually results in lingual collapse of the lower anterior
segment.
Contraindications
Serial extraction should not be performed in the following
circumstances:
• Class I malocclusions where the lack of space is slight
and the teeth show only mild crowding.
• Where there is a skeletal discrepancy in the dental
arches.
• When there is a deep overbite or an open bite.
• When there are permanent teeth congenitally absent
from the dental arch.
Treatment stages in serial extraction
• First, the primary canines are removed to allow
spontaneous alignment of the permanent incisors.
• The primary first molars are removed to allow the
eruption of the first premolars.
• Once the first premolars are erupted, they are removed
and a space maintainer is issued to allow the permanent
canines to erupt.
• Further orthodontic treatment is usually required to
align teeth to achieve correct root angulation and incisor
torque.
Thus, serial extraction is a planned procedure that demands
a minimum of 5 years' supervision by the dentist of the
developing occlusion. Without such a commitment, the
objectives will not be fully achieved and at times, the child
is then left with a more severe malocclusion.
View chapter Explore book
Dentoalveolar Surgery
Leonard B. Kaban, Maria J. Troulis, in
Pediatric Oral and Maxillofacial Surgery, 2004
General Considerations
Inadequate space with dental crowding frequently con-
tributes to failure of eruption of the maxillary canine. When
an impacted canine is encountered, the choices of
management are: (1) surgical exposure of the tooth,
followed by orthodontic movement to its proper place in
the dental arch, (2) extraction, or (3) autotransplan-tation
(i.e., extraction and replantation into the normal position).
The ideal treatment is prevention by close observation of
the child's eruption pattern and jaw and dental
development. When necessary, space is created by serial
extraction of deciduous teeth and permanent premolars or
by orthodontic therapy, or by both.
An impacted canine must be treated in the context of the
patient's overall dental development and ortho-dontic
status. Before any procedure is carried out, the orthodontic
plan should be established; in most cases, orthodontic
appliances should be in place. For example, in the patient
who requires premolar extractions for space and alignment
of teeth, a deeply impacted canine might be sacrificed
because the prognosis for ortho-dontic movement is poor
or because it is desirable (for medical or behavioral
reasons) to shorten treatment time. The first premolar is
then used in the canine position. Alternatively, if extraction
is not appropriate, it might be necessary to surgically move
an impacted canine to its proper position (Figure 10-1).
Root development of the canine is also important. If the
root is fully developed and the apex is closed, there is little
chance for spontaneous movement into the arch after
exposure (Figure 10-2). If, however, root develop-ment is
incomplete and the canine is vertical in orien-tation,
significant spontaneous movement often occurs. The ideal
time for exposure of an impacted canine (if one is sure the
tooth will not erupt naturally) is when the root is developed
but before the apex is closed. In very high impactions,
exposure can be carried out when there is approximately
two-thirds root development.
View chapter Explore book
Theory of Extraction Techniques
B.E. Richter, D. Raynie, in
Comprehensive Sampling and Sample Preparation, 2012
2.06.2 Operation
ASE was first described in 1995 and 1996.1–9 As a technique,
it has grown steadily in use since that time. There have
been reports of a few laboratory-built systems, but the
majority of the work reported in the literature has been
accomplished on commercially available hardware. This
section discusses the operation of a serial extraction
apparatus, although the operation of parallel systems is
similar.
Figure 1 shows a schematic of accelerated solvent
extraction. To perform an extraction, the solid sample is
loaded into a stainless steel extraction cell (1–100 ml), and
the frit-containing endcaps are tightened by hand onto the
cells. The filled extraction cells are loaded on a carousel and
collection vials are loaded in the lower collection vial
carousel. A robotic arm transfers each cell separately into
the oven for extraction. The oven is maintained at the
chosen operating temperature throughout the extractions
(room temperature to 200 °C). The cell design and
associated fluid apparatus allow operation of the
extractions at elevated pressures (500–3000 psi) to
maintain the solvents as liquids at temperatures above their
boiling points. The temperature and pressure are controlled
independently for each cell regardless of the solvent used,
the moisture or mineral content of the sample, or any
characteristic of the matrix that might affect the actual
extraction temperature. This is an advantage when
compared to MAE in which the actual pressure and
temperature of the extraction will be influenced strongly by
the above-mentioned sample parameters.
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Figure 1. Schematic and flow diagram of the ASE process.
Once the cell is in place in the oven, the pump immediately
begins to deliver the solvent of choice to the extraction cell.
Single solvents or premixed solvents can be used from a
single bottle, or any combination of three to four different
solvents can be programmed using a solvent controller
module. Once the solvent has made its way through the
sample cell and reaches the collection vial, the static valve
closes to allow pressurization of the cell. Since the solvent
expands as it heats, the pressure in the cell will increase
when the static valve closes. When the pressure reaches a
value of 200 psi above the set point, the static valve rapidly
opens to relieve the pressure and then closes again. The
pump also delivers fresh solvent to the cell in an effort to
return the pressure to the set point value. This addition of
fresh solvent during ASE is analogous to fresh solvent
dripping down from the condenser onto the extraction
thimble during Soxhlet extraction.
The first period of the extraction is called the heat-up time
as the cell contents are heated by the oven to the chosen
operating temperature. For ASE, heat-up times vary
between 5 min for 100 °C and 9 min for 200 °C. After the
heat-up time, the extraction enters a static period with a
duration chosen by the user. Typical static times are 5 min,
but can vary from 1 to 99 min. After the static time, fresh
solvent is flushed through the cell to remove extracted
analytes while the sample and solvent are still hot. The
amount used for the flush can vary from 5 to 150% of the
volume of the cell used for the extraction (40–60% is most
common). The user can choose the number of times the
sample will be in the static mode, and this is entered as the
number of static cycles. The flush volume is divided by the
number of static cycles so that fresh solvent is present at
the beginning of each static cycle. In other words, if one
static cycle is chosen, the entire flush volume will be
pumped through the cell at the end of the static time. If
three static cycles are chosen, a third of the total flush
volume will be pumped through the cell at the conclusion
of each static cycle. The number of static cycles can be
programmed from one to five, with one cycle being the
most common. Following the final solvent flush, solvent is
purged out of the cell using nitrogen at 150 psi for a
predetermined period of time. The total time for the
extraction is usually less than 15 min, and the amount of
solvent used is approximately 1.5 times the volume of the
extraction cell (i.e., about 15 ml for a 10-ml cell). The
extracts are delivered to the collection vials through a filter
and, in many cases, do not need any additional preparation
prior to analysis. Since the extract is diluted by the total
volume of extraction solvent plus the flush solvent,
sometimes a further concentration step is required (i.e.,
evaporation, solid-phase extraction (SPE), etc.) when
performing trace analysis.
Upon completion of the purge step, the cell is returned to
the carousel and the next sample is taken to the oven to
begin the extraction process again. Current instrumentation
allows for unattended overnight operation of the extraction
system without user intervention. Under method control,
each sample will be extracted using the same conditions.
When using schedule control, each cell can be extracted
using different conditions, including the solvent if a solvent
controller is used. Many features are in place to minimize
safety issues with using solvents at elevated temperatures
and pressures. Flammable vapor sensors, liquid leak
detectors, checks for vial overfill conditions, three levels of
over-pressurization prevention (electronic and mechanical),
solvent flow monitoring, and pneumatic source pressure
monitoring are among the safety measures in place on ASE
instrumentation.
View chapter Explore book
Hydrocarbon Fingerprinting Methods
Gregory S. Douglas, ... Kevin J. McCarthy, in
Introduction to Environmental Forensics (Third Edition), 2015
8.5.1.1 Sample Extractions
With the exception of NAPL samples, chemicals of
environmental concern are not typically found in the
environment in a form or concentration that can be directly
analyzed or detected by modern analytical equipment. Over
the last 20 years, analytical chemists have developed
specialized techniques for the isolation and concentration
of organic chemicals in a range of environmental media.
The following are descriptions of proven methods for the
preparation of environmental and quality control samples
for the analysis of semivolatile hydrocarbons.
8.5.1.1.1 Water Samples
Samples of water are extracted for low-level hydrocarbon
analysis using solvent extraction techniques consistent with
EPA Method 3510, Separatory Funnel Liquid-Liquid Extraction
(EPA, 1997). Typically, 1 L of water is added to a 2 L
separatory funnel and fortified with known amounts of
surrogate QC compounds. The water sample is then serially
extracted three times with approximately 60 mL aliquots of
dichloromethane (DCM). The DCM extracts are combined,
residual water is removed with anhydrous sodium sulfate,
and extract concentrated to 0.5–1.0 mL. The Kuderna
Danish (KD) apparatus is used to reduce large volumes of
solvent (generally 20 to 200 mL) to a more concentrated
volume, whereas a nitrogen gas evaporation (NEvap)
technique is used to slowly reduce smaller volumes of
solvent (generally less than 20 mL) to instrumental
preinjection volumes of typically 1 mL or less. Regardless of
the concentration technique, that final concentration of
solvent should be carried out at ambient temperatures in
order to minimize the loss of the most volatile compounds
in the extract (e.g., naphthalene). Following final
concentration, most water extracts are spiked with an
appropriate internal standard and analyzed by appropriate
chromatographic techniques. If necessary, extracts with
high levels of nontarget analytes that interfere with the
chemical analysis can be further purified with specialized
sample cleanup methods (EPA, 1997).
8.5.1.1.2 Soil and Sediment Samples
Sediments and soils are primarily inorganic mineral
particulates with adhered, entrained, or adsorbed natural
and anthropogenic organic materials. Sediments and soils
are grouped with other types of particulate matrices (e.g.,
concrete, stone, asphalt, brick, glass, plastic, metal, and
others) classified as “solids.” In our experience, solid
samples are best prepared for analysis using solvent
extraction and cleanup techniques promulgated by the
NOAA National Status and Trends Program (NOAA, 1993,
1998, 2002). These methods were specifically developed for
the efficient extraction of highly sequestered organics in
complex media, like sediments and tissue, which require
active particle motion and long solvent exposure
conditions. Extraction efficiency for semivolatile
compounds using these methods is generally good for labile
and residual compounds present in the semivolatile
hydrocarbon range.
Large solid samples (e.g., concrete or asphalt) are subjected
to particle reduction (e.g., crushing, drilling, or cutting).
Free liquid is typically decanted out of the sample jar.
Extraneous plant debris (twigs, large roots, branches, and
leaves) and large stones are removed from the sample. The
remaining solid sample is homogenized and an aliquot (5 to
10 g wet weight) is removed for the determination of the
sample dry weight. Approximately 30 g (wet weight) of
sample is transferred to an extraction vessel (e.g.,
precleaned and disposable 8 oz. jars with a Teflon® cap
liner). A smaller sample weight can be used if gross
hydrocarbon contamination is present. Surrogate standards
are spiked into the sample for the purpose of monitoring
the extraction and sample processing efficiency and should
be adjusted to the extent possible for the estimated level of
contamination in the sample (low, moderate, or high).
Anhydrous sodium sulfate is mixed into the solid sample to
absorb excess water from the sample and facilitate sample
extraction with the organic solvent. An organic extraction
solvent, such as dichloromethane (DCM), is added to
the extraction vessel before it is sealed and
serially extracted three times (30–60 mL). In conjunction
with the motion of the particles, the duration of the
extraction is important because it facilitates the
mobilization of tightly bound compounds. The first of the
three serial extractions is shaken or tumbled for a
minimum of 12 hours (one time), whereas the second and
third extractions are carried out for at least one hour. This
high-energy extraction technique agitates the particles over
a long period of time in order to efficiently extract target
analytes sequestered in the recess of the sediment matrix.
The sample may be centrifuged between the extractions to
optimize solvent recovery and decanted and collected into
a precleaned Erlenmeyer flask. The combined extract is
then filtered and dried through a glass fiber filter
containing anhydrous sodium sulfate to remove particles
and water from the extract. The KD apparatus is used to
remove large volumes of solvent (generally 20 to 200 mL),
whereas the NEvap technique is used to remove smaller
volumes (generally less than 20 mL) of solvent at a slow
evaporation rate and at ambient temperature or less to the
final preinjection volume (e.g., 1 mL). It is recommended
that activated copper be added to sediment samples for the
removal of excess elemental sulfur in marine sediment
samples. At this point solid sample extracts other than soils
and sediments are spiked with an appropriate internal
standard (IS) and analyzed. Complex sample extracts (e.g.,
soil and sediments) with high levels of nontarget analytes
can be further purified or fractionated (e.g., aliphatic and
aromatic hydrocarbons) with specialized sample cleanup
methods to improve method detection limits.
8.5.1.1.3 Tissue Samples
Tissue samples are prepared for analysis using the solvent
extraction and cleanup techniques followed by the NOAA
National Status and Trends Program (NOAA, 1998). These
methods were specifically developed for the efficient
extraction of highly sequestered organics in complex media
such as sediments and tissue, which require active particle
motion and long solvent-exposure conditions.
Tissue samples are collected (e.g., fillet, shucked, cut into
pieces), transferred into a precleaned extraction vessel
container, and thoroughly homogenized using a Tekmar
Tissuemizer. Fish may be filleted and composited prior to
extraction (EPA, 1993b). Approximately 30 g (wet weight)
of homogenized tissue is used for solvent extraction and an
additional 5 g to 10 g (wet weight) is used for dry weight
determination.
Anhydrous sodium sulfate is added to the homogenate to
absorb water and facilitate extraction. The tissue
homogenate is mixed with DCM and macerated three
times, each for two minutes, with a Tissuemizer. The
sample is centrifuged between extractions to optimize
solvent recovery and the solvent is decanted and collected
in a precleaned Erlenmeyer flask. The combined extract is
filtered and dried through a glass fiber filter containing
anhydrous sodium sulfate. A KD apparatus is used to
concentrate the large volume of extraction solvent
(generally 20 to 200 mL) to approximately 10 mL, followed
by further concentration by NEvap to a precleanup volume
of approximately 1 mL. At this point, the tissue extracts are
subjected to sample cleanup procedures as discussed in
Section 8.5.1.2 to remove coextracted biogenic materials
that interfere with instrumental analysis.
8.5.1.1.4 Nonaqueous Phase Liquid (NAPL) Samples
Nonaqueous phase liquid samples such as petroleum or tar
products can be prepared for analysis following an
adaptation of EPA Method 3580, Waste Dilution (EPA, 1997).
The NAPL samples are generally liquid but can be solidified
hydrocarbon residues that dissolve readily in DCM. An
aliquot of the NAPL sample is quantitatively transferred into
a dilution vessel (e.g., 10 mL scintillation vial with a
Teflon®-lined cap). Dichloromethane is added to the
volumetric and the sample is mixed or vortexed until the
NAPL is dissolved. The NAPL extract is filtered through a
glass fiber filter into a 10 mL volumetric flask. The NAPL
extract is spiked with surrogate and brought up to the
calibrated volume. An aliquot of the extract is removed to
determine the sample mass or oil weight. Liquid
hydrocarbon samples (e.g., diesel fuel or crude oil) may also
be directly analyzed without sample dilution and cleanup
using direct injection GC/MS methods also known as whole
oil analysis (see Section 8.4.9). For these analyses, the
density of the NAPL must be determined to calculate the
weight of the sample that is injected on the instrument.
Internal standards may also be added to the NAPL prior to
instrumental analysis.
8.5.1.1.5 Wipe Samples
Sorbent wipes can be used to effectively collect organic
residues off various kinds of environmental or structural
surfaces or from floating “sheens” of contaminants from
water. The best wipe material for trace level measurements
is prerinsed and dried Teflon® netting or glass fiber filter.
This material is used routinely by the US Coast Guard to
collect oil sheen samples on surface waters (Greimann et
al., 1995). During emergency situations, when it is better to
collect a sample than not, other materials such as cotton
pads or paper towels have been used for the collection of
grossly contaminated surfaces with the understanding that
the use of these materials may contaminate the sample
with mineral oil, antibiotic agents, and other interferences.
Thus, “blank” wipes or “field blanks” should be analyzed in
order to appreciate the potential contribution of the
sampling material to the authentic sample(s). Wipes are a
very useful replacement for equipment rinse blanks after
decontamination in the field because they do not require
cumbersome bottles of purified water and they can be
processed as solid samples in the laboratory.
Surface wipes usually employ a Teflon® swab (or
equivalent) to wipe a specific surface area (e.g., 10 cm x 10
cm; EPA, 1998). The analyte concentration can be reported
as concentration per unit area, e.g., µg/100 cm2. Sheen
samples on water are collected with a Teflon® swab or net
that is placed or drawn through a floating organic layer.
Wipes containing adsorbed, but nonflowing, NAPL can be
spiked with surrogate standards and serially extracted with
organic solvent as previously described for solid samples. In
the case of wipes that contain free-flowing NAPL, remove
an aliquot of the hydrocarbon liquid and process as a NAPL
(described previously).
The raw Teflon® material used to construct wipe samplers
usually contains low levels of hydrocarbon oligomers that,
if used untreated, can interfere in GC analysis of
hydrocarbons extracted from such materials. All Teflon®-
wipe sampling material must be rigorously precleaned with
methylene chloride, stored in precleaned glass jars, and
blank tested prior to use. It is not recommended that these
devices be stored for long periods of time prior to use. In
addition, a field blank of the wipe should be provided to the
laboratory during each sampling event.
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Orthodontics, Premolar,
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Mineral Trioxide Aggregate
, Therapeutic Procedure,
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WATER ANALYSIS | Overview
H. van der Jagt, H.F. Reijnders, in
Encyclopedia of Analytical Science (Second Edition), 2005
Continuous LLE
An automated continuous LLE apparatus, based on the
mixer–settler principle, can be constructed for use in the
field. The apparatus consists of two extractors in series for
serial extraction and can be applied at different depths. The
units are loaded with ∼200 ml of solvent and have the
capacity to extract some 100 l of water, depending on the
solvent used.
Another apparatus for continuous extraction consists of
three inverted 250 ml volumetric flasks. A vibratory mixer
is used for vigorous shaking of all three flasks. A 10 l sample
can be siphoned through the apparatus in ∼4 h and
extracted, with a total solvent volume of 10 ml.The
advantage is that no concentration step is involved.
Simple batch extraction is most widely used. The extraction
efficiencies for semivolatile organic pollutants decrease in
the order: pentane⩾hexane>hexane saturated with
methanol>isooctane>15% (v/v) acetone in hexane⩾benzene.
Pentane and hexane show the least interference with
standard peaks during GC. Hexane is a more attractive
extraction solvent than pentane because the volatility of
pentane makes it difficult to handle, particularly when it is
used with an automatic injector. The single-step LLE
procedure has some limitations when applied to samples
containing large numbers of compounds. Analytical results
for such samples are likely to be semiquantitative and will
require careful evaluation. The hexane extraction procedure
is, however, very useful as a simple, rapid screening method
that can be applied to complement other methods. A low
solvent-to-water ratio will give problems in the analysis of
more foaming samples such as discharge water and the
amount of solvent has to be increased. The use of large
volumes of organic solvents and the high concentration
factor of 100–10000 subsequently requires solvents of very
high purity. Concentration by evaporation gives a loss of
volatile compounds and is laborious. A relatively new
development is the technique using supercritical fluid
carbon dioxide.
View chapter Explore book
Missing Maxillary Lateral Incisors
Marco Rosa, Bjørn U. Zachrisson, in
Esthetics and Biomechanics in Orthodontics (Second Edition),
2015
Step 1: Space Closure and Correction of the
Malocclusion
The extraction of two premolars in the mandibular arch is
sometimes necessary, depending on the extent of lower
arch crowding, incisor protrusion, lip posture, and expected
growth pattern. Typically, a normal mandibular arch form
should not be expanded and should maintain the pre-
treatment shape. The maxillary archwires should be
coordinated with the lower ones.
The space closure in the upper arch may be performed
without major problems in crowded cases and in Class II
malocclusions. If the diagnosis is made in the early mixed
dentition, a serial extraction strategy may sometimes be
effective to shorten the treatment time stage with fixed
appliances (see Fig. 25-3).
The problems become more relevant when treatment must
be achieved with maximum anterior anchorage. In such
cases, conventional biomechanics (Fig. 25-10, A and B) are
usually sufficient to close the spaces.3 However, moving
each tooth individually is time consuming and the patient's
compliance with intermaxillary elastics is essential to
achieve the treatment goal in a reasonable time span.
Usually space closure is made with a heat-treated 0.016-
inch × 0.022-inch stainless steel archwire, using brackets of
different slot sizes: 0.018-inch on the central incisors and
canines and 0.022-inch on the premolars and molars.
With recent technical advances, including absolute skeletal
anchorage with two connected palatally inserted mini-
screws,34–38 maximum anchorage problems can be
overcome and all posterior teeth can be moved
simultaneously forward without compliance problems. This
system allows mesial movement of molars and premolars
with no extra anchorage and/or Class III elastics39 (Fig. 25-
10, C-H).
The mesial movement of the first premolar may be
complicated in the presence of two divergent roots. It may
be indicated to slightly rotate such premolars to prevent the
buccal root from moving into the cortical plate, which
would slow down the movement and potentially produce a
risk for periodontal tissue breakdown.
Furthermore, the curve of Spee should be flattened to allow
proper orthodontic finishing. Fixed appliances are
necessary in the mandibular arch, at least in the final stages
of treatment. A correct cusp to fossa relationship should be
achieved on the upper second premolars, together with a
solid stable occlusion with no notable CO-CR discrepancy.
Sometimes slight selective grindings are necessary.
Another possible alternative treatment plan for agenesis
patients who show much gingiva when smiling is to close
the spaces anteriorly and open up space for a third
premolar in the posterior areas (see Fig. 25-9; Fig. 25-11).
View chapter Explore book
Treatment Planning and Management
of Orthodontic Problems
John R. Christensen, ... Michael A. IgnelziJr., in
Pediatric Dentistry (Sixth Edition), 2019
Severe Crowding
Crowding of more than 5 mm is considered severe. This
amount of crowding is managed either with generalized
arch expansion or with removal of selected permanent
teeth. This degree of generalized arch expansion can be
accomplished with different appliances but usually requires
bodily tooth movement with fixed appliances. Achieving
considerable expansion often is difficult. Incisor position,
profile, and periodontal status all influence whether the
patient should be treated without extraction. Patients with
this degree of crowding are most appropriately referred to a
specialist.
The decision to extract teeth is based on the factors listed
previously and is further influenced by the location of the
crowding, the position of the dental midline, and the dental
and skeletal relationships of the patient. After careful case
analysis, appropriate teeth may be removed to make
subsequent tooth movement easier to accomplish and to
minimize the effects of extraction on the profile. The
permanent first premolar is most often selected for
extraction because it is located at a midpoint in the arch
and because the space it occupies can be used to correct
midline problems, incisor protrusion, molar relationship
problems, or crowding. Other teeth can be removed
depending on the specifics of the case and the type of
therapy used. Management of extraction cases is best
performed by a specialist.
In some children, crowding is so severe in the mixed
dentition that expansion is not feasible, and extractions are
necessary to obtain a suitable occlusion that is in harmony
with the supporting structures and the facial profile. In
these cases a planned sequence of extractions of primary
and permanent teeth can benefit the patient by reducing
incisor crowding and irregularity in the early mixed
dentition, which will make subsequent orthodontic
treatment easier and quicker. The extractions also make
room for teeth to erupt within the alveolus and through
keratinized tissue rather than being forced buccally or
lingually into positions that may affect the periodontal
health of the teeth. Guidance of eruption and serial
extraction are terms used to describe this sequence of
extractions.74,75 Guidance of eruption was originally
developed to manage severe crowding without orthodontic
appliances but now is viewed as the first step in treatment
culminating in fixed orthodontic appliance therapy. For this
reason the clinician should consult with a specialist before
embarking on a planned extraction sequence.
Guidance of eruption should be considered an option when
crowding is greater than 10 mm per arch, a measurement
that should be confirmed by space analysis after the
permanent lateral incisors have erupted. In addition, the
patient should have a class I dental and skeletal pattern
with good lip and incisor position (unless one is prepared
to address these problems) because guidance of eruption
does not correct skeletal problems. Guidance of eruption
begins in the early mixed dentition with the eruption of the
lateral incisors (Fig. 36.46A). If a significant arch length
discrepancy is predicted, the primary canines should be
removed. This allows the incisors ample room to erupt and
align (see Fig. 36.46B). Typically, the incisors also tip
lingually and upright, causing the bite to deepen.
Faciolingual incisor displacement usually improves, but
rotations are more resistant to spontaneous correction.
The child is observed for 2 years or until it appears that the
canines and premolars are ready to erupt. At that time,
another space analysis should be completed to ensure that
the arch length deficiency is still great enough to warrant
permanent tooth extraction, and a radiograph should be
obtained to determine the position of the unerupted teeth.
The goal of treatment is to encourage the eruption of the
permanent first premolar so that it can be extracted before
the permanent canine erupts (see Fig. 36.46C).
Unfortunately, the mandibular canine erupts first nearly
half the time in the mandibular arch. If it appears that the
canine is ahead of the premolar and will erupt facially, the
primary first molar should be removed when half to two-
thirds of the first premolar root is formed. At this stage of
root development, premolar eruption will be accelerated,
and the premolar will erupt before the canine enters the
arch. This makes removal of the first premolar much easier.
In the maxillary arch the first premolar normally erupts
before the canine, and this is not a problem. In some cases
the primary first molar is removed, but the permanent
canine still erupts before the first premolar. This can lead to
impaction of the first premolar, requiring surgical removal.
Similarly, it may become apparent that the permanent
canine will erupt before the first premolar regardless of the
extraction sequence. In this situation the primary first
molar and first premolar are removed at the same time.
This procedure is called enucleation because the premolar is
removed from within the alveolar bone.
Surgical removal of teeth from within the alveolar bone
should be avoided if possible because it carries the
potential for creating bone and soft tissue defects. These
occur if the alveolar bone is fractured or removed. New
alveolar bone will not be stimulated to form because no
tooth will erupt through this area. Surgical soft tissue
defects resolve infrequently.
An alternative extraction sequence has been advocated to
prevent lingual tipping of the lower incisors and the
subsequent increase in overbite, but this sequence is
recommended only when incisor crowding is limited. The
primary canine is not removed when the lateral incisor
erupts. Instead, the primary canine is retained, and the
primary first molar is extracted to accelerate the eruption
of the permanent first premolar. This allows some anterior
crowding to resolve. The premolar is extracted when it
erupts into the arch. The primary canine is often extracted
at the same time as the premolar or is left to exfoliate when
the permanent canine erupts. The drawback of this
alternative is that substantial incisor crowding is not readily
resolved, which somewhat defeats the goal of selective
tooth removal to encourage good dental alignment.
View chapter Explore book
Early Treatment: where are we today?
Padhraig S. Fleming, James Andrews, in
Seminars in Orthodontics, 2023
Relief of crowding
While transverse expansion can be undertaken early both
to address transverse relationships and alleviate crowding,
crowding is typically addressed in the late mixed or
permanent dentition. An exception to this is the use of
serial extraction in the presence of severe crowding to
simplify comprehensive orthodontic care in adolescence.44
In the permanent dentition, space may be generated either
by a decrease in the amount of tooth structure (extractions
or inter-proximal reduction) or by increasing the arch
length by transverse expansion, advancement of the
incisors or distal movement of the molars. In the late mixed
dentition, however, the leeway or ‘E’ space may also be
utilized for the relief of crowding (Figs. 4 and 5). This space
constitutes the difference in width of the primary canine
and molars compared with the permanent canines and
premolars. In the mandibular arch, this amounts to 2–
2.5 mm per quadrant with slightly less space available in
the maxillary arch, although inter-individual variation does
exist. Fixed auxiliaries such as palatal and lingual arches
may be useful in preserving the leeway space helping to
resolve crowding in 60% of patients in one study.45
However, based on the availability of teeth, in the absence
of other features of malocclusion, the optimal timing for
correction of dental crowding is the late mixed or early
permanent dentition.
Fig 4
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Fig. 4. (a–e): An 8-year-old male presented with a Class I incisor relationship in
the early mixed dentition with a maxillary median diastema and significant
crowding of both arches (a). The primary canines were extracted promoting
spontaneous temporary alignment of the incisors (b). As anticipated, the
underlying crowding persisted (c) and required loss of 4 first premolars (d).
Three years following their loss the alignment was significantly improved with
a 15-month course of appliance therapy required to detail the occlusion (e). (For
interpretation of the references to color in this figure legend, the reader is
referred to the web version of this article.).
Fig 5
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Fig. 5. (a–k): A 10-year-old female with a mild Class III incisor relationship
presented with significant underlying crowding exacerbated by premature loss
of primary teeth (a–e). Following loss of the remaining primary teeth, the upper
second primary molars and all first premolars were extracted. Space was
preserved using a lower lingual arch and an upper removable appliance. Mild
crowding persisted in the permanent dentition (f). This was addressed with a
short course of appliance therapy (g–k).
View article
Proceedings of the Joint Symposium
Sponsored by the American Academy
Of Pediatric Dentistry and the American
Association Of Endodontists
Anna B. Fuks CD, in Journal of Endodontics, 2008
This randomized, clinical trial compared gray MTA, white
MTA, and FC in 72 molars of 24 children. Only restorable
molars without clinical and/or radiographic evidence of
pulp degeneration were included. Each child had at least 3
molars with severe carious involvement and received
pulpotomies with all 3 medicaments. An additional 15
carious teeth planned for serial extractions after 6 months
were selected for the histologic part of the study. All
pulpotomies were performed by the same pediatric dentist,
and outcome assessment after 12 months was done by 2
“blinded” pediatric dentists. Four children (12 molars)
dropped out, and of the remaining 60 teeth in 20 patients, 1
(gray MTA) exfoliated normally, and another 6 teeth (4
white MTA and 2 FC) failed as a result of abscesses. The
remaining 53 teeth appeared to be clinically and
radiographically successful. In the histologic study, both
types of MTA formed thick dentin bridges, but the gray MTA
appeared to be better than white MTA and FC as a pulp
dressing, because it presented the closest to normal pulp
architecture.
View article
Special issue: Pathogenomics
Torsten Hain, ... Trinad Chakraborty, in
International Journal of Medical Microbiology, 2007
Looking at the cell wall, the issue of covalently linked
proteins was first addressed. A newly developed gel-less
strategy with greatly increased sensitivity compared to 2D-
PAGE was developed and used in a comparison of a
sortaseA-deletion mutant with the wild-type strain,
demonstrating that SrtA is required for the cell wall
anchoring of InlA. This work was extended to cover SrtB
and further SrtA substrates (Bierne et al., 2002). Because
the majority of surface proteins are not covalently linked to
the cell wall, this initial investigation was followed by an
analysis of non-covalently cell wall-associated proteins. For
this purpose, a new method for the isolation of defined
surface proteome fractions based on serial extraction of
proteins with different salts was developed and particular
attention paid to ensure the integrity of the cell membranes
during the treatment. Fifty-five cell wall-associated surface
proteins were identified by N-terminal sequencing and
mass spectrometry. About 16% of these proteins are of
unknown function and three proteins have no orthologs in
the non-pathogenic L. innocua. Remarkably, a relatively
high number of proteins with a function in the cytoplasmic
compartment were identified in this surface proteome.
These proteins had neither predicted or detectable signal
peptides nor could any modification be observed except for
removal of the N-terminal methionine. One of these
proteins, enolase, was shown to be present in the cell wall
of the pathogen by immuno-electron microscopy and, along
with heat shock factor DnaK, elongation factor TU, and
glyceraldehyde-3-phosphate dehydrogenase, it was found
to be able to bind human plasminogen with high specificity
in overlay blots and surface plasmon resonance
experiments. The data suggest a possible “moonlighting”
role of these proteins as receptors for human plasminogen
on the bacterial cell surface, where the recruited host
protease might assist in the invasion process (Schaumburg
et al., 2004).
View article
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