EXTRACTIONS

In orthodontics

By Under the Supervision of

Fatma Mohamed Haggag Orthodontics Department
Suez Canal University
 OUTLINE
1. Definition
2. Historical Review
3. Reasons for Extraction
4. Advantages and Disadvantages of Extraction
5. Factors Affecting Choice of Extraction
6. Types of Extractions in Orthodontics
7. Guidelines for Extraction of Primary teeth
8. Guidelines for Extraction of Permanent teeth
9. Guidelines for Extraction in Class I Malocclusion
10. Guidelines for Extraction in Class II Division 1 Malocclusion
11. Guidelines for Extraction in Class II Division 2 Malocclusion
12. Guidelines for Extraction in Class III Malocclusion
 Definition
• It is the painless removal of teeth from its
socket
HISTORICAL REVIEW
• In 1771 Hunter first advised extraction for gaining
space in the book of natural history of tooth.
• 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.
 GREAT EXTRACTION CONTROVERSY
• Based on 2 school of thought by EH ANGLE and
CALVIN CASE in 1920:
• Angles believed the full retention of the teeth for the
correction of the malocclusion. According to him if
crowded teeth were aligned in correct relation to each
other, improved function of masticatory apparatus
will result in growth of the jaws, creating adequate
space for dentition.
• Calvin case believed in that tooth may be extracted
occasionally to produce long lasting results. this leads
to the great extraction controversy in 1920s
• By the late 1940s Charles Tweed and Raymond
Begg reintroduced extraction into the orthodontics
after being dissatisfied with the extent of relapse
noted in previous non-extraction cases
 Why do we take teeth out?
These include:
• General factors like caries, periodontal problems, or severe
malposition
• Relief of arch length discrepancy
• Correction of incisor relationships and overjet
• Correction of overbite (flattening of the curve of Spee requires
space)
• Reduce the fullness of the lip, e.g., Bimaxillary protrusion
• Allow molar distalization
• Management of tooth size discrepancy (Abnormal size or form)
• Provision of anchorage and allow the use of intermaxillary elastic
• Interceptive orthodontic treatment
• Enhance stability (weak evidence)
 Reasons for Extraction
1. Relieve crowding.
2. Correct anteroposterior dental arch relationship.
3. Improve facial esthetics.
 Extraction for the relief of crowding: If the
dentition is too large to fit in the dental arch
The size of the dental arch is governed mainly by:
• a) Basal bone size
• b) Function of the oral musculature.
• Sometimes it is not acceptable to increase the size
of the dental arch, except in rare circumstances,
because the increased dental arch dimensions would not
be tolerated by the oral musculature.
 Extraction for the correction of the
anteroposterior dental arch relationship
• It is frequently necessary to remove teeth to give space for
correction of discrepancies in arch relationship as in class ll cases
when the upper arch is too far forward in relation to the lower
• The upper arch, or more often the anterior segment of the arch, is
usually moved back in the course of treatment; unless the arch is
spaced.
• This backward movement can only be made if teeth are removed
to provide space.
 Extraction for the improvement
of facial esthetics
• It is usually done in cases of Class I Angle's malocclusion
with (bimaxillary dento-alveolar protrusion)
 Advantages
• Controllable outcome
• Improved Stability
• Reduces the protrusive facial appearance
• Minimal gingival recession
 Disadvantages
• Treatment time is prolonged as the treatment is carried
out in stages spread over 2-3 years.
• It requires the patient to visit the dentist thus patient
co-operation is needed.
• As the extraction spaces are created that close
gradually the patient has a tendency of developing
tongue thrust.
• Extraction of buccal teeth can result in deepening of
the bite.
• If the procedure are not carried out properly there is a
risk of arch length reducing by mesial migration of the
buccal segment.
 Factors affecting choice of extraction
1. Condition of the teeth
• Fractured, hypoplastic, grossly carious teeth and
teeth with large restorations are the teeth of
choice for extraction in orthodontics.
• Tooth condition must be balanced with other
considerations of tooth position in deciding an
extractions.
 Factors affecting choice of extraction
2. The position of teeth:
• The position of the tooth apex must be considered,
as it is more difficult to move the apex than to move
the crown.
• Severely malposed teeth and which are difficult to
align are usually the teeth of choice for extraction.
 Factors affecting choice of extraction
3. The position of crowding:
• If crowding in one part of the dental arch, it will be
corrected if extractions are carried in the same part
of the arch rather than un-crowded part.
• This principle is not considered a rule
eg., crowding of incisors is usually relieved by extract
of premolars which will give pleasing final appearance
and occlusal balance.
 Types of extractions in Orthodontics
1. Balancing extraction
2. Enforced extraction
3. Compensatory extraction
4. Wilkinson's extraction
5. Serial Extraction
6. Therapeutic extraction
1) BALANCING EXTRACTION
It is defined as the removal of teeth
in the opposite side of the same arch
to preserve symmetry of the arch.
If a tooth is removed only from one
side of the arch with tight tooth
contacts, it may result in drifting of
the rest of the teeth towards
extraction site.

2) ENFORCED EXTRACTION

If prognosis of tooth is very poor ,
extraction of that tooth is mandatory.
3) COMPENSATORY EXTRACTION
Extraction of teeth from opposite arch
• It is carried out to maintain buccal occlusion. In
Class I bimaxillary cases it is usually advised to
extract tooth in both arches to preserve molar
relationship.
 4) WILKINSONS EXTRACTION
Wilkinson advocated extraction of all the 4 first permanent molars
between the age of 8.5 and 9.5 yrs.
ADVANTAGES
• Provides additional space for eruption of 3rd molar.
• Crowding of arch is minimized
• They are more caries prone tooth.
DISADVANTAGES
• Offer minimum space to relieve crowding in anterior region
• Mesial tipping of 2nd molar
• Rotation of 2nd premolar and 2nd molar
• Adequate anchorage for tooth movement by orthodontic appliance is
lost on removing first permanent molar.
5) Serial Extraction
• It is an interceptive orthodontic procedure usually initiated
in the early mixed dentition. It includes the planned
extraction of certain deciduous teeth & later specific
permenent teeth in an orderly sequence & pre-determined
pattern to guide the erupting permenent teeth into a more
favourable position.
• This treatment technique involves the sequential removal
of deciduous teeth to facilitate the unimpeded eruption of
the permanent teeth (Graber et al.2017).
• Class I malocclusion cases are more ideal for serial
extraction because the dentition is basically in a favorable
relationship and successful treatment is possible with a
minimum of mechano-therapy.
• Advantages:
• Treatment is more physiologic as it involves guidance of teeth into
normal positions.
• Psychological trauma associated with malocclusion can be
avoided by treatment of the malocclusion at an early stage.
• It eliminates the duration of multi-banded fixed treatment and
lesser retention period is indicated at the completion of
treatment.
• Better oral hygiene is possible thereby reducing the risk of caries.
• Health of investing tissue is preserved.
• More stable results
are achieved as the tooth material
& arch length are in harmony.
• Disadvantages:
Problems in the serial extraction:
• It can result in flat face with prominent chin. Patient may
look aged.
• It can result in lingual inclination of incisors.
Anterior Crossbite:
• Dento alvealor ant. Crossbites:
Ant. crossbite in which 1 or more maxillary teeth are in
lingual relation to the mandibular ant. is termed as
“Dentoalveolar ant. Crossbites”.
This is manifested as single tooth crossbite & usually occurs
due to over retained deciduous teeth.
• Functional ant. Crossbites:
• Also called “Pseudo Class III Malocclusion”.
• Occurs as a result of occlusal prematurities.
• Skeletal ant. Crossbite
• These are usually a result of skeletal discrepencies in
growth of maxilla or the mandible.
• Ant. cross bite can be a result of maxillary retrognathism
or hypoplasia or mandibular prognthism.
Indications:
• Minimum 7.0 mm of crowding in the anterior areas per
arch
• Severe arch length-tooth material discrepancy of 10 mm
or more in the arch
• Coincident upper and lower midlines
• Bilateral Class I molar relationship
• Balanced skeletal pattern in all three planes of space
(Jeryl et al.2015, Phulari.2011).
Contra-indications
• Class III and Class II molar relationships
• Unbalanced skeletal patterns of any kind
(transverse, anteroposterior, or vertical)
• Unequal crowding in the maxillary and
mandibular arches
• Unequal crowding bilaterally in either arch
• Midline discrepancies (more than 2 mm)
• Open bites or impinging deep bite
•Presence of midline diastema
(Jeryl et al.2015, Phulari.2011).
 Guidelines for extraction
of Primary teeth
• When an orthodontist is dealing with enforced
extraction of a deciduous tooth, a treatment plan should
be made whether to remove the unsavable tooth,
extract a contralateral tooth from the same arch
(balance), or extract a tooth from the opposing arch
(compensation).

• Before planning extraction of primary teeth, it is

essential to undertake a thorough radiographical
examination to assess the presence, position, and
formation of the developing permanent dentition.
 Extraction of Primary teeth

Primary incisor:
Early loss of primary incisors has
little effect on the developing
permanent dentition, so it is
unnecessary to balance or
compensate for the loss of a primary
incisor.
Primary canine:
Early unilateral loss of a primary
canine can result in centerlines
deviation, especially in crowding in
the arch, which necessitates the
need for balancing extraction
 Extraction of Primary teeth
First Primary molar:
A balancing extraction may be needed if the
loss is unilateral, specifically in a crowded
arch. If mandibular first deciduous molars
are lost, some consideration can be given to
compensating extractions in the maxillary
arch to preserve the buccal segment
relationship.
Second primary molar:
Balancing the loss of a primary second molar
is not indicated because it has no
appreciable effect on the centerline.
However, if they are lost bilaterally in the
upper or lower arch, it can alter the molar
relationship; hence, in these cases,
compensating extractions may be
6) Therapeutic Extraction
It is the extraction of permanent teeth for the purpose of
orthodontic correction
• Before planning extractions of any permanent teeth, it is
essential to ensure that all remaining teeth are present and
developing appropriately.
Factors affecting the choice of teeth for extraction:
• Prognosis
• Position
• Amount of space required and where
• Incisor relationship
• Anchorage requirements
• Appliances to be used (if any)
• Patient’s profile and aims of treatment
Incisors are rarely the first choice for
extraction due to the risk of
compromising aesthetics.
It can also be difficult to fit four incisors
in one arch against three incisors in the
opposing arch
However, indications
• Incisor has poor prognosis or compromised periodontal
support
• Buccal segments are Class I, but there is lower incisor
crowding
• Adult patient who has a mild Class III skeletal pattern with well
aligned buccal segments
Fixed appliances are often required to align the teeth following
extraction of an incisor and a bonded retainer may be required to
Canines
Canines form the cornerstone of the
arch and are important both
aesthetically and functionally (providing
canine guidance in lateral movements).
However, if severely displaced or
ectopic, they may need to be extracted.
• A reasonable contact between the
lateral incisor and first premolar is
possible, but rarely occurs without the
use of fixed appliances. If a canine is
missing, the occlusion must also be
checked to ensure that there are no
unwanted displacing contacts, caused
by a lack of canine guidance.
First premolars
• These are often the teeth of choice to extract when the
space requirement is moderate to severe. Also, extraction
of a first premolar in either arch usually gives the best
chance of spontaneous alignment.
• This is particularly true in the lower arch where, provided
the lower canine is mesially inclined, spontaneous
alignment of the lower labial segment may occur.
• This spontaneous improvement is most rapid in the first 6
months after the extraction.
• In the upper arch the first premolars usually erupt before
the upper canines, so the chances of spontaneous
improvement in the position of this tooth can be achieved
if the first premolar is extracted just before the canine
emerges.
• A space maintainer may be required to keep the space
open for the upper canine.
• Typically, when using fixed appliances, 40–60 per cent
of a first premolar extraction space will be available for
the benefit of the labial segment without anchorage
reinforcement.
• The reason why there is some loss of the space
available from the extractions is due to mesial
movement of the posterior teeth.
 Second premolars

Indications for extraction of second premolars include:

• Mild to moderate space requirement (3–8 mm space
required)
• Space closure by forward movement of the molars, rather
than retraction of the labial segments is indicated
• Severe displacement of the second premolar
Extraction of the second premolars is preferable to first
premolars when there is a mild to moderate space
requirement.
• This is because the anchorage balance is altered, favoring
space closure by forward movement of the molars. Hence,
only about 25–50 per cent of the space created by a
second premolar extraction is available to allow labial
segment alignment.
• Fixed appliances are often required to ensure good
contact between the first molar and first premolar,
particularly in the lower arch.
• Early loss of the second deciduous molars often results
in crowding of the second premolars palatally in the
upper and lingually in the lower.
• In the upper arch, extraction of the displaced second
premolar on eruption is often indicated.
• While, in the lower arch, extraction of the first
premolars is sually easier and in most cases uprighting
of the second premolars occurs spontaneously following
relief of crowding.
 First permanent molars
• Extraction of first permanent molars often makes
orthodontic treatment more difficult and
prolonged. However, their extraction may need to
be considered if they have a poor long-term
prognosis
 Second permanent molars
Extraction of second permanent molars has been suggested in
the following cases:
• To facilitate distal movement of upper buccal segments
• Relief of mild lower premolar crowding
• Provision of additional space for the third permanent molars,
thus avoiding the likelihood of their impaction
• Extraction of the upper second molar will not provide relief of
crowding in the premolar or labial segments, due to mesial
drift.
• Relief of mild crowding in the lower premolar region may be
possible, as well as providing additional space for eruption of
the third permanent molar.
• The eruption of the third permanent molars is never
guaranteed, but the chances can be improved by the correct
The following features should ideally be present
• Angle between the third permanent molar tooth germ
and the long axis of the second molar is 10–30°
• Crypt of developing third molar overlaps the root of the
second molar
• The third permanent molar is developed to the
bifurcation
Even if these criteria are satisfied, eruption of the lower
third molar into occlusion cannot be guaranteed, and it
should be made clear to the patient that a course of fixed
appliance treatment to upright or align the third molar
may be necessary.
Example of a case where second permanent molars were
extracted. Patient with mild lower arch crowding who had both
lower second molars removed in an attempt to treat mild crowding
in the lower premolar region.
(a) DPT radiograph prior to extraction of both lower second molars
(the upper second molars were not extracted because of concerns
over the prognosis for the upper first molars);
(b) DPT radiograph 2 years after the extractions showing eruption
of both lower third molars
 Third permanent molars
• In the past, early extraction of these teeth has been
advocated to prevent lower labial segment crowding.
However, it is much more likely that late lower incisor
crowding is caused by subtle growth and soft tissue changes
that continue to occur throughout life
• It is now not acceptable to extract third molars purely on the
grounds of preventing crowding of the lower labial segment
 Guidelines for Extraction in
Class I Malocclusion

Less than 4 mm arch length discrepancy:

• Extraction rarely indicated (only if there is
severe incisor protrusion or in a few instances,
a severe vertical discrepancy) (Phulari.2011).
• Some cases, this amount of crowding can be
managed without arch expansion by slightly
reducing the selected teeth, being careful to
coordinate the amount of reduction in the
upper and lower arch (Proffit et al.2013)
Arch length discrepancy 5 to 9 mm:
• Non-extraction or extraction treatment possible
(Phulari.2011, Proffit et al 2013).
• The decision depends on both the hard- and soft-
tissue characteristics of the patient and on how
the final position of the incisors will be controlled,
any of several different teeth could be chosen for
extraction.
• Non-extraction treatment usually requires
transverse expansion across the molars and
premolars, and additional treatment time if the
posterior teeth are to be moved distally, to
increase arch length
Arch length discrepancy 10 mm or more:
• Extraction almost always required
(Phulari.2011, Proffit et al.2013).
• For these patients, the amount of crowding
virtually equals the amount of tooth mass being
removed, and there would be little or no effect on
lip support and facial appearance.
• The extraction choice is four first premolars or
perhaps upper first premolars and mandibular
lateral incisors.
• Second premolar or molar extraction rarely is
satisfactory because it does not provide enough
space near crowded anterior teeth or options to
 Guidelines for Extraction in Class II
Division 1 Malocclusion
• Class II is defined by the British Standard Institute as the
lower incisor edges lying posterior to the cingulum plateau of
the upper incisors.
• In cases of class II division 1 malocclusion, there is increase
in the overjet and the upper central incisors are usually
proclined
• Treatment of class II has several different modalities: growth
modification, orthodontic camouflage, surgical correction.
 Extraction of all first premolars is usually
indicated in the management of increased
overjet associated with a class I or mild class II
skeletal pattern with severe upper and lower
crowded arches. (Pattern 1)

 Extraction of maxillary first premolars and

mandibular second premolars is usually the
extraction of choice in the management of
increased overjet associated with a class I or mild
class II skeletal pattern with moderately crowded
arches. (Pattern 2)
 When treating class II in the absence of
crowding with extraction of upper first
premolars, the anterior segment of the upper
arch is distalized to the extent of a premolar
width (7 mm) so that cuspids can establish a
class I relationship, while molars correct to class
II full unit. (Pattern 3)

 Extraction of maxillary first permanent molars

only is indicated in cases of badly decayed first
molars and severe crowding in the upper arch
with mild crowding in the lower arch. (Pattern 4)
Removal of second permanent molars for correction of
class II division 1 is suggested in case of excessive buccal
inclination of the incisors, no diastema, minimal overjet,
presence of conveniently positioned and shaped third
molars, patients with a dolichocephalic facial pattern, a
tendency toward vertical growth, and the need for first
permanent molar retraction
•Extraction is recommended to decrease the likelihood of
open bites and in cases of existing pathologies, such as
buccal eruption, crown or root anomalies, caries or
extensive restorations, and enamel defects.
• Second permanent molar extraction for the correction
of class II division 1 malocclusions often streamlines
therapy and significantly shortens treatment time by
making first molar distalization easier and faster. (Pattern 5)
 In cases of congenitally missing upper lateral incisors or if
they are pegshaped, extraction is preferred with lower
second premolars, closure of the space with upper
canines, and correcting the buccal segment to class I
(Pattern 6)

1 2 3 4 5 6

Upper 4s Upper 4s Upper 4s Upper 6s Upper 7s Upper 2s

Lower 4s Lower 5s Lower 5s

 Guidelines for Extraction in Class II Division 2 Malocclusion

• Class II division 2 is defined as when the upper central

incisors are retroclined and the laterals are proclined, or
when all upper incisors are retroclined.
The overjet is usually minimal but could be increased.
•When treating class II division 2 cases, it is best to avoid
extraction. As most of the cases are low-angle cases, no
extraction is advised and distalization
or stripping is preferred.
If crowding is marked,
extractions will be required
• Extraction in the upper buccal segment with
distalization is beneficial in cases where the
incisor relationship needs correction and relief of
crowding without affecting the overbite. It could
also be used to correct buccal segment crowding
in cases of class II division 2
But when extraction is decided, upper and lower
second premolars are preferred, while some
other cases benefit from extraction of the
second permanent molars and distalization
with a headgear.
• Extraction of upper and lower second premolars
is preferred to first premolars in cases of severe
crowding to prevent the excessive movement of
the lower incisors lingually, which leads to
deepening of the bite
 Guidelines for Extraction in
Class III Malocclusion
The British Standard definition of class III incisor
relationship includes those malocclusion where the
lower incisor edge occludes anterior to the
cingulum plateau of the upper incisors
• Treatment of class III has several different
modalities:
• Early orthopedic treatment
(rapid palatal expansion+ face mask);
• Orthodontic camouflage
(extraction/nonextraction);
• Orthognathic surgery.
• The extraction pattern for class III malocclusion
could be of either camouflage or orthognathic
surgery.
The extraction of choice for camouflage is
extraction of lower first premolars and upper
second premolars. This is considered to resolve
large mandibular crowding or no crowding but
edge-to-edge incisor relationship, and include
significant tipping of mandibular arch. Maxillary
arch has no or mild crowding (pattern 1).
The second pattern is to extract one central
incisor either right or left. It is the tooth of choice
in situations where crowding is not large or
situation of Bolton discrepancy.
• The only disadvantage could be of upper/ lower
midline mismatch and the need for permanent
rigid lingual retainer as mandibular arch with
three incisors has a tendency for lingual collapse
and deep bite (pattern 2).
Extraction of all first premolar is carried out
sometimes in severe crowding or in cases of
class III complicated with anterior open bite
(pattern 3).
In high angle cases with presence of third
molars, the extraction of the first permanent
molars might be a good option to solve the
problems of anterior–inferior crowding and
vertical growth, as well as to attain class I molar
relationship. (pattern 4).
In cases where the one side is a class I and the
other is class III, extraction of either first
premolar/first permanent molars on the class I
side, and extraction of first lower premolar and
upper second premolar is advocated to correct
the anterior and posterior occlusion to finish in a
class I incisor, canine, and molar relationship.
(pattern 5).
In cases that requires orthognathic surgery,
decompensation is required, and is done in the
presurgical orthodontic phase It is to make the
class III look more prominent (worse). Here
extraction of upper first premolars and lower
second premolars is required (pattern 6).
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