International Journal of Applied Dental Sciences 2019; 5(3): 370-378

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2019; 5(3): 370-378 Serial extraction in orhodontics
© 2019 IJADS
www.oraljournal.com
Received: 09-05-2019 Abu-Hussein Muhamad and Nezar Watted
Accepted: 13-06-2019
Abstract
Abu-Hussein Muhamad Serial Extraction or the guidance of eruption is an age old procedure to correct crowded arches and is still
Universitätsklinikum Würzburg, used in routine dental practice. But the efficacy of this procedure has always been controversial and it
Klinik und Polikliniken für requires very precise clinical skill for a favorable outcome. This article presents a review regarding the
Zahn-, Mund- und
proper selection of cases for serial extraction, its limitations and various adjuncts that are required to get
Kieferkrankheiten der Julius-
good results.
Maximilians-Universität
Würzburg, Germany, University
of Debrecen/ Hungary, Faculty Keywords: Serial Extraction, primary teeth, mixed dention, developing malocclusion
of Dentistry of the University of
Sevilla/Spain, Arab American Introduction
University/ Jenin, Palestine Therapeutic extraction can be defined as the removal of the teeth for the purpose of
orthodontic treatment. Certain sound healthy teeth may have to be extracted to facilitate proper
Nezar Watted
Universitätsklinikum Würzburg, alignment of other teeth in case of severe arch length-tooth material discrepancy or correction
Klinik und Polikliniken für of sagittal relationship. Before planning extraction of any permanent teeth, it is essential to
Zahn-, Mund- und ensure that all permanent teeth are present and developing appropriately [1].
Kieferkrankheiten der Julius- Balancing extraction can be defined as the removal of the contralateral tooth on the opposite
Maximilians-Universität
side of the same arch (although not necessarily the same) in order to prevent midline shift and
Würzburg, Germany, University
of Debrecen/ Hungary, Faculty preserve the symmetry [2]. If a tooth is removed from one side of the dental arch which is
of Dentistry of the University of crowded or which has complete contact of teeth all around, there is a tendency for the
Sevilla/Spain, Arab American remaining teeth to move toward the extraction space, this in form of forward movement of
University/ Jenin, Palestine teeth behind the space and movement of anterior teeth across the center of the arch resulting in
asymmetry. It is usual to balance extractions in order to prevent such asymmetry [2, 3].
If the dental arch is spaced, there is no need for balancing extraction since there is no tendency
for remaining teeth to move toward the extraction space [4].
Compensating extraction can be defined as the removal of the equivalent tooth from the
opposing arch on the same side to maintain the occlusal relationship (buccal occlusion)
between upper and lower arches [3]. In some cl I crowding cases, it is necessary to extract in
both arches to maintain occlusal relationship (lateral symmetry). Compensating extractions
preserve inter-arch relationship by allowing the posterior teeth to drift forward together [5].
Serial extraction can be defined as sequential removal of some of the deciduous teeth followed
by permanent teeth to guide the teeth in to normal position. This procedure is usually done at
mixed dentition period [6].
Serial extraction is defined as the planned and sequential extraction of certain deciduous teeth
followed by removal of specific permanent teeth in order to encourage the spontane-ous
correction of irregularities [7]. This article presents a review regarding the proper selection of
cases for serial extraction, its limitations and various adjuncts that are required to get good
Correspondence results.
Abu-Hussein Muhamad
Universitätsklinikum Würzburg,
Klinik und Polikliniken für Historical development
Zahn-, Mund- und Serial extraction is not new. It has been of interest to dentist for many years. Throughout the
Kieferkrankheiten der Julius- history of dentistry it has been recognized that the removal of one or more irregular teeth
Maximilians-Universität would improve the appearance of the reminder [8, 9].
Würzburg, Germany, University
of Debrecen/ Hungary, Faculty Paisson was the first person who pointed the extraction procedure in order to improve the
of Dentistry of the University of irregular alignment and crowding of teeth. Bunon in 1743 [10], in his “Essay on the Diseases of
Sevilla/Spain, Arab American the teeth” proposed the removal of deciduous teeth to achieve a better alignment of permanent
University/ Jenin, Palestine teeth. The interest on serial extraction increased following World War II.
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The names that stand out particularly for the modern stated that mandibular arch is the final diagnostic guide, with
development of the serial extraction concept are Kjellgren of particular emphasis on the harmonious relation of the
Sweden Hotz of Switzerland, Heath of Australia and Nance, mandibular incisor to the basal bone. Slight irregularity or
Hoyd, Dowel and Mayne of the United States [11, 12, 13]. moderate crowding are not abnormal but extreme crowding,
Nance presented clinics on his technique of „progressive gingival recession and premature loss of deciduous
extraction‟ in 1940 and has been called as the father of „serial mandibular canines are not acceptable deviations from the
extraction‟ philosophy in the United States. Kjellgren in 1940 normal [14, 15].
termed this extraction procedure as „planned‟ or According to Lloyd (1956) patients with short arch lengths or
„progressive‟ extraction procedure of teeth [11, 12]. very short intercuspid width would be suitable cases for serial
Hotz named the same procedure on “Guidance of eruption”. extraction. He advised serial extraction to be done in all types
According to him the term guidance of eruption is of class I malocclusion and class II div I malocclusion that
comprehensive and encompasses all measures available for show a severe lack of arch length or severe lack of intercanine
influencing tooth eruption [13]. Widespread adoption of serial space in both jaws to accommodate the incisor teeth in non
extraction as a corrective treatment procedure continues to be rotated position. They are further characterised by a good
a source of concern to all Pedodontists who are aware of its facial profile, the overbite ranges from slight to severe and
limitations as well as of its possibilities. The principle reason age of patient is somewhere between 6 and 9 years [16].
is that itsm application involves growth prediction. Every Malocclusions that have lingually locked maxillary incisors
serial extraction diagnosis is based on the promise that future i.e. anterior crossbite or buccal teeth in crossbite or that lack
growth will be inadequate to accommodate all of the teeth in a occlusion but show deficient arch length or lack of intercanine
normal alignment [1, 3, 5]. space are mechanically treated for a short period until the
Serial Extraction should be diagnosed in the early mixed cross bite is changed and serial extraction is continued.
dentition period. It is most effective in Class I malocclusions. Bimaxillary protrusions show beneficial results from serial
Especially where we find marked irregularity of anterior extraction procedure. A lip retracting exercise in these cases is
teeth, premature loss of one deciduous canine, mid line helpful in the uprighting and lingual positioning of the
deviation, displaced lateral incisors, gingival recession and incisors. It is suggested that a headplate be used to
alveolar destruction of labial surface of anterior teeth. In such supplement the diagnosis.
cases decrease in tooth mass improves the alignment of Another type of malocclusion where serial extraction can be
anterior teeth and the gingival tissues [6-9]. helpful is that in which mandibular arch has sufficient arch
length with excellently aligned incisors but in which the
Overview of dental development maxillary arch shows a decided lack of space for the erupting
• Incisor liability: The four maxillary permanent incisors lateral incisors due to forward eruption of buccal teeth rather
are, on the average, 7.6 mm larger than the primary than to lack of intercanine space. Early removal of maxillary
predecessors. For the mandibular incisor segment, the deciduous canines will prevent the lingual locking of the
permanent successors are 6.0 mm larger. This difference maxillary permanent lateral incisors [16].
was termed the Incisor Liability by Warren Mayne and it Maj and Luzi (1960) suggested that serial extraction should
varies greatly from person to person [4]. not be prescribed in those cases in which alveolar growth
• Interdental spacing: One of the first observation to be increments can be successfully stimulated and a good long
made on young patient. Interdental spacing may range lasting correction can be achieved with a full complement of
from 0 to 10.0 mm in the maxillary arch, but averages teeth [17].
about 5.0 mm. In the mandibular arch interdental spacing According to Mayne (1968), if the crowding is extremely
can range from 0 to 6.0 mm, averaging 3.0 mm. Lack of severe, with irreparable insults occurring to the investing
interdental spacing must be considered a serious handicap tissues, then logic demands the early removal of deciduous
in achieving normal alignment [5, 5]. cuspids,permitting the most rapid unravelling of the crowded
• Intercanine width changes: Between the primary and teeth and their greatest lingual adjustment, both these
mixed dentitions there is an increase in arch width accomplishments will improve investing tissue health [18].
between the primary canines. For the maxillary arch, Profitt writes that only when there is extreme severe crowding
Intercanine widths correlate with the timing of the late of 10mm or more is there a chance that a reasonably
mixed to early permanent dentition exchange. After 10 satisfactory result can be achieved by serial extraction alone
[2]
years of age there is little mandibular intercanine width .
change to be expected in either boys or girls [6] Figure1 Dewel (1969) concluded that an authentic serial extraction
• Arch length changes: Distance around the arch from the case has markedly irregular anterior teeth, premature loss of
mesial surface of one first permanent molar to the one or more of the deciduous canines, various median line
counterpart on the other side. Arch length may and deviations, impacted or displaced lateral incisors, a gross
generally does, change during the growth period. reduction in arch length and frequently, gingival recession
Changes vary considerably between individuals and and alveolar destruction along the labial surfaces of one or
between the maxillary and mandibular arches. In most both the central incisors.
cases, arch length actually decreases in the mandibular Cephalometrically, the typical class I extraction case presents
arch during the growth period [7]. a flat or straight facial pattern and the incisors are vertical and
in a more acceptable relation to the N-Pogonion facial plane
[19]
Review of literature .
Dewel suggests that serial extraction can be applied in certain Giorgio Maj (1970) advocated the removal of deciduous
Class II and Class III irregularities but almost invariably only canines when lack of space for mandibular incisor is greater
as a part of treatment already in progress. In class I serial than 2.5 mm. This would allow better alignment of incisors
cases active orthodontic treatment more often is postponed and prevent any tissue damage in the region of malposed teeth
[20]
until a later date and frequently it can be omitted entirely. He .
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Ruff (1976) concluded that in class I mixed dentition cases, region permits the tongue to flow into the space which results
decision for serial extraction should be made only after the in a major problem in habit correction during the active stages
size of unerupted teeth is determined and after at least one of treatment [15].
year of growth observations verified by cephalometric Lloyd (1956) found that disadvantage of serial extraction is
analysis. Cases with a discrepancy of 4 mm or more still have some lingual inclination of the incisor teeth particularly the
a chance, if the growth potential is good. Cases showing a mandibular incisors which cause their elongation and
greater arch length discrepancy will generally become increased incisal overbite. Use of a lingual appliance may
extraction cases [21]. minimize lingual inclination [16].
Odenrick and Troeme (1985) proposed when cephalometric Moorrees (1965) research showed that as the mandibular
evaluation indicates an orthognathic or retrognathic profile, permanent incisors erupt the primary mandibular canines
slightly hyper divergent, with facial skeletal dimensions less move laterally. When these teeth come into occlusion with the
than average, in a patient whose dental casts indicate above primary maxillary canines, they in turn are moved laterally
average incisor width, serial or early extraction therapy is one (secondary spacing) and the space created enables the
of the treatment modalities that may be considered [22]. permanent maxillary lateral incisors to emerge into a
Jacquelin and Berthet (1991) proposed that serial extraction favourable alignment. If the primary canines are extracted,
has limited indications which need to be respected in order to when this natural phenomenon is occurring secondary spacing
preserve the child’s future dental health. It is indicated for may not occur [30].
class I malocclusion with severe crowding or moderate Salzmann (1966) wrote that since it is not possible to predict
crowding associated with bimaxillary protrusion [23]. the exact time of tooth emergence on the basis of the root
length of the teeth or the chronologic or skeletal age of the
Borderline cases patient, extraction of deciduous molars actually can initiate
According to Dewel (1969), borderline cases generally have malocclusion [31].
good facial patterns, moderate loss of arch length, a good Ringenberg (1967) listed the disadvantages of serial
muscular environment and a satisfactory direction of skeletal extraction as increased overbite, lingual tipping of incisors,
growth. Drastic procedures should be avoided, all possible scar tissue in the extraction space, diastema and alteration of
diagnostic records be secured and then place the patient under tongue function [32].
observation to determine whether his individual growth trend Mayne (1968) pointed out that inadequate attention has been
will make it possible for him to retain all of the teeth [19]. paid to those situations which accounts for many cases of
According to Maj (1970), a favorable element in the serial extraction resulting in 3-5 mm of spacing remaining in
borderline cases is the presence of a space of 1-2 mm between the extraction site. Space which must be closed through
unerupted second molar and the distal surface of the first anterior movement of remaining posterior teeth [18].
molar [24]. Dewel (1969) concluded that active mechanotherapy has to be
Jacob Harris (1972) feels that lower archpresents the more instituted to close the remaining spaces, to open the bite,
difficult problem in determining whether or not a case will upright teeth on either side of extraction sites and realign
require extraction. Maxillary arch is often amenable to rotated and malposed incisors and canines. It has been
treatment with various types of headgear and/or palatal disillusioning to learn that serial extraction, in itself rarely
splitting devices in order to increase arch length [25]. creates acceptable occlusal relation and that certain adverse
Dewel (1976) suggests that if the dental arches are fairly well reaction will result if procedure is not followed by
developed and if there is only a moderate discrepancy comprehensive orthodontic treatment [19].
between tooth mass and supporting bone it may still be Freeman (1977) reported in a study of 1455 patients that only
possible to retain all the teeth. If incisor alignment is also 1% of the patients treated with serial extraction would not
acceptable than the patient should only be placed under need orthodontic treatment. 81% will need full banded
preliminary serial supervision in order to determine future orthodontic treatment [33].
growth trends. It will also help to avoid all extraction errors Dewel (1976) reported that extraction decisions are much
until a time arises when growth prediction can be established more difficult and demanding in the early mixed dentition
on a more rational basis [26]. than in the later permanent dentition [26].
Lieberman (1984) claimed that these borderline cases can be Persson (1989) performed a longitudinal study on serial
started without tooth extraction with a specific time limit set extraction cases and found that despite earlier tooth removal
for reevaluation. The initial response to treatment may guide on average crowding developed to about the same degree as
the orthodontist to continue on non extraction basis or to that of a non extraction normal occlusion sample [34].
revert to tooth extraction. The term ‘therapeutic diagnosis has Little, Riedel and Eugst (1990) evaluated the long term serial
aptly been applied to describe this procedure’ [27]. records of patients who had undergone serial extraction plus
comprehensive treatment and retention and found that the
Limitations anticipating future stability, the primary rationale for serial
Dewel (1954) commented that even when serial extraction is extraction, was not confirmed in their study. They realized
necessary, premature removal of teeth involves the risk of that postretention irregularity is an inevitable response in
retarding future development in arches that are already cases with inadequate pre treatment arch length [35].
deficient [28]. Graber writes that the removal of the first premolar allows the
Bjork (1951) believes extraction of deciduous teeth for tipping together of the crowns accentuating the “V” or
correction of crowding not justified as it retards the basal “ditch”. Seldom does the distance between the apex of canine
mandibular growth [29]. and mandibular second premolar decrease on its own [3].
Dewel (1957) found that even when authentic serial extraction Hollander (1992) reported that although extraction of canine
is indicated, premature removal of teeth involves the danger on the opposite side is advocated following unilateral loss of
of retarding future development in arches that already are canine and has been taught for many years, no data exists to
deficient. Also, prolonged absence of teeth in the premolar confirm that the midline will resolve automatically with
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extraction of antimere leaving the stability of incisor of treatment/observation time was significantly longer for
symmetry in question. He says it would be more beneficial to serial extraction cases than for extraction and orthodontic
leave the antimere intact [36]. treatment done in permanent dentition. However the results
Wagner and Berg (2000) in a study found that the number of and outcome of treatment was similar in both the groups [37].
appointments was significantly higher and the total duration

Fig 1: An example of a case where the upper arch was expanded, using a removable appliance (Shown), to correct a posterior crossbite,
associated with a mandibular displacement, and to create space for the relief of mild maxillary crowding.

Rationale of serial extraction expansion of the maxillary and mandibular arches with fixed
1. Growth of jaws: It is in Class I cases that serial ex-traction or removable ap-pliances. The normal growth of dental,
finds its most successful application. If there is a Class I skeletal and soft tissue influences the result of serial
malocclusion with generalized crowding in a normally extraction [38]. Figure 2
growing child, the clinician would be most unwise to resort to

Fig 2: Moyers has reported that at least 50% of normal developing dentitions have a flush terminal plane relationship that corrects itself only
with the loss of the deciduous molars at the end of the mixed dentition period with the utilization of the leeway space. This Class II tendency
may be accentuated with a distal step, if there is a morphogenetic Class II pattern or an excessively deep overbite and resultant functional
retrusion.

2. Dentitional adjustment in the anterior segment during 3. Dentitional adjustment in the posterior segment during
first transitional period: The fact that the permanent incisors second transitional period: The combined widths of the
are larger than the deciduous counterparts is quite obvious, mandibular deciduous canine, first molar and second molar
even to the patient. Direct measurement of this incisor averages to 1.7 mm, that is, more than the combined widths of
liability, as it is termed by Mayne, is possible and the three permanent successors. As Nance indicated, there is
recommended. The deciduous–permanent tooth size less width differential in the maxillary arch (average width
differential averages 6–7 mm, even when there is no difference 1 mm). This ‘leeway space’ exists on both sides, so
crowding. Any appreciable incisor liability, which would not it would average 3.4 mm in the mandibular arch and about 2
get adjusted despite the contributions by the adjustment mm in the maxillary arch. 7 Can it be used for incisor
crowding? This leeway space is required to correct the flush
mechanisms, and strongly point to a program of guided
terminal plane relationship which is a normal, transient
extraction in the mixed dentition period [3].
developmental phenomenon and is seen in a large percentage
of cases [39].

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Fig 3: (a) There is a potential lack of space for eruption of the maxillary lateral incisors. (b) Early loss of the maxillary

When the permanent teeth replaces primary teeth, there is radiographically and a skeletal pattern within normal
mesial shift of the mandibular first molar utilizing the leeway limits [1, 2, 3].
space and mesiobuccal cusp of the maxillary first molar locks  Tooth size- jaw size discrepancy with severe arch length
into the mesiobuccal groove of the mandibular first permanent deficiency which could be:
molar. The ‘leeway space’, then, is usually a reserved bit of  True (hereditary) (non-pathologic) which is indicated by:
arch length to allow for the adjustment of maxillary and unilateral or bilateral premature loss of deciduous canine,
mandibular dental arches during the critical tooth exchange midline shift of mandibular incisors due to displaced
period.7 When this space is used, holding back the permanent lateral incisors, localized gingival recession in the labial
mandibular molars to gain anterior arch length, it may very aspect of lower anterior region, ectopic eruption of teeth,
well have a Class II tendency and result in full Class II crowding of the anterior segment of arch, canine being
division 1 malocclusion. When the settling in the cusps and blocked out labially [1, 2].
grooves is prevented, it may create premature contacts that  Environmental (pathologic) which is indicated by: tooth
intensify bruxism and functional problems [2]. Figure 3 ankylosis, mesial migration of permanent 1st molar
following premature loss of deciduous molar or due to
4. Dental crowding is the result of inadequate arch size. Serial severe interproximal caries or improper filling that does
extraction aims to correct this discrepancy by reducing the not restore the ideal contour mesiodistally [3].
tooth material. Why not intercept the developing  Cl I malocclusion cases with maxillary mandibular
malocclusion in the early mixed dentition by relieving alveolodental protrusion (bimaxillary alveolodental
crowding to provide a chance for nature to adapt with protrusion) [2].
adequate space, instead of waiting for all permanent dentition  In mesial step terminal plane in mixed dentition
to emerge into a full-blown malocclusion? The answer is developed in to cl I permanent relationship with
conditionally corroborative. But, before commencing on this malocclusion [4].
‘robbing Peter to pay Paul’ technique, the orthodontists must  Cl II malocclusion cases if there is maxillary
question themselves [3]. alveolodental protrusion while the mandibular dentition
is normal, the serial extraction is indicated in upper arch
5. Physiological tooth movement or drifting occurs at the time only. extraction for self-correction [6] Figure 4.
and site of extraction. Teeth move both mesially and drift
distally. This principle is being utilized in serial [1, 2]. Contraindications for serial extraction include
1. Congenital absence of teeth providing space
2. Mild to moderate crowding
3. Deep or open bites
4. Severe Class II, III of dental/Skeletal origin
5. Cleft lip and palate
6. Spaced dentition
7. Anodontia / oligodontia
8. Midline diastema
9. Dilacerations [1-7]

Advantages of serial extraction procedure

 More physiologic treatment as teeth are guided into
normal positions using physiologic eruptive forces.
 Serial extraction allows the teeth to erupt over the
alveolus and through -keratinized tissue, rather than
Fig 4: Upper and lower first molars are grossly carious. Inter
being displaced buccally or lingually.
radicular crescent of the second molars is just forming. This would
be an appropriate stage to extract the upper and lower first  Reduce the duration & cost of active orthodontic
permanent molars as an interceptive measure. treatment at later stage.
 Health of investing tissues is preserved with less potential
Indications for serial extraction procedure for iatrogenic orthodontic damage like root resorption,
 Class I malocclusion with an arch size-tooth size enamel decalcification.
deficiency of 5 mm or more per quadrant (10 mm or  More stable result
more for arch), normal eruption sequence as assessed  Less retention period is required.
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 Better oral hygiene [1-6] Mixed dentition analysis helps in determining the space
requirement for erupting posterior teeth [1, 3, 39, 40].
Disadvantages of serial extraction procedure
 Long-term procedure that requires thorough knowledge Radiographs
of growth, development, eruption sequence and Various radiographic views recommended are:
calcification of permanent teeth. No single approach can  Intraoral periapical view
be universally applied.  Lateral cephalogram-to analyse the skeletal relation and
 It is done as inter-canine growth is occurring and hence it direction of growth using cephalometric analysis.
is difficult to assess accurately how crowded the dentition Orthopantomograph (OPG)
will be.  To detect congenitally missing teeth and supernumerary
 Prolonged treatment time with multiple visits (2-3 years). teeth
 Patient cooperation is very important.  To carry out radiographic mixed dentition analysis
 Most cases treated by serial extraction need to be  To assess dental age
followed by active orthodontic treatment (fixed  To assess the amount of root development and possible
appliance) to achieve ideal leveling& alignment, root eruption pattern
parallelism, closure of residual spaces, correction of deep  To detect any bony pathologies [1, 3].
bite
 Tendency to develop tongue thrust. Photographs
 Tendency to increase over bite (deepening of the bite). Pre, mid and post-treatment intra- and extra-oral photographs
 Residual spaces can remain between the canine and 2nd are taken. They act as permanent records of pre-treatment
premolar. state, improvements during the procedure and also help in
 Subjecting the child to multiple progressive extraction patient motivation [15].
visits [1-6].
Procedure
A number of extraction sequences are in use and the choice of
a particular method depends on individual case. No single
extracton sequence applies to all patients. Some of the
commonly used methods are described here.
 Dewel’s method
 Nance method
 Tweed’s method Figure 5
 Grewe’s method.
 Moyers Method

Dewel’s Method (1978) (Extraction of CD4)

Dewel proposed a three-step serial extraction procedure in
1978. This is the most satisfactory order in most patients even
Fig 5: Serial extraction today [14, 15, 19, 26, 28].

Diagnosis and treatment planning Step 1: Extraction of deciduous canines

Extraction of any tooth is a critical step in orthodontic In this step, the deciduous canines are extracted at around 8-9
management. Thus the decision of resorting to serial years to create space for the alignment of the incisors. The
extraction should always be based on comprehensive main objective of extracting primary canines is to establish
assessment of dental, skeletal and soft tissues. Serial the integrity of upper and lower incisors. This prevents the
extraction is not a single-decision but a multi-decisional, development of lingual crossbite of maxillary laterals and
time-lined process where factors such as the amount of resultant mesial migration of maxillary canines.
crowding, arch length requirements, whether to extract the
next set of teeth or not, and when to extract are reevaluatedat Step 2: Extraction of deciduous first molars
each visit by the patient. Thus serial extraction is a continum In this step, deciduous first molars are extracted when first
of decision making process rather than a single-time diagnosis premolars reach half of the root length as evidenced by
[36, 37, 38, 39]
. radiographs. This would be some 12 months after the
The following investigations are recommended after a extraction of deciduous canines at around 9-10 years of age.
thorough clinical examination: The objective of deciduous first molar extraction is to
accelerate the eruption of first premolars. This ensures that the
Orthodontic study models first premolars emerge into oral cavity, before the eruption of
Moderate to severe arch length-tooth material discrepancy of permanent canines.
not less than 5–7 mm should exist to undertake the serial
extraction procedure. Step 3: Extraction of first premolars
Study models are required for: In this step, first premolars are extracted as they are emerging
 Assessing the morphology of teeth into oral cavity and when the permanent canines have
 Assessing the dental arch form developed beyond half of the root length.
 Evaluation of occlusion Extraction of first premolars facilitates proper eruption and
 To perform model analyses—Carey’s analysis in the alignment of permanent canines after serial extraction
lower arch and Arch perimeter analysis in the upper arch. procedure, the teeth are fairly aligned. However, the

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establishment of proper intercuspation usually requires b) C + D ----- 4

orthodontic mechanotherapy of minimal duration, although it c) D ------ C + 4
may not be necessary in some cases. Figure 6 d) C ---- D + Enucleation of 4
e) C ---- D ---- E ---- 4
f) C ----- D ----- No permanent tooth extraction
g) Occassionally some or all the permanent 2nd premolars
are substituted for first premolar.

Where, C is the deciduous canine.

D is the deciduous 1st molar
E is the deciduous 2nd molar 4 is the first premolar
The list indicates that there is no ideal extraction sequence
and that serial extraction treatment, is not an uncomplicated
procedure [44, 45, 46, 47].

Fig 6: Serial extraction

Nance method
Nance method of serial extraction is the modification of
Tweed’s method, which involves the extraction of the
deciduous first molars, followed by the extraction of the first
premolars and the deciduous canines [1, 3, 41, 42].

Grewe’s method
Grewe’s method of serial extraction is based on the planning
of extraction sequence for different clinical conditions [1, 3, 43,
44]
.

Moyers method
Indications Fig 7: Canine on upper left is impacted, despite serial extraction
When crowding seen in central incisor region. Fairly eruption procedures. Stringent and protracted mechanotherapy was required
of lateral incisors. to achieve results shown in bottom view.
Stage I: (Extraction of all deciduous lateral incisors). It helps
in alignment of central incisors [1, 44, 45]. Precautions
Stage II: (Extraction of all deciduous canines after 7-8 Operator must always check that the permanent
months). It helps in alignment of lateral incisors and provides successors
space for lateral incisors. Are present. Of good quality. Of adequate morphology i.e.
Stage III: (Extraction of all deciduous first molars). It size and shape. At proper position. Have a sound, well-formed
stimulates eruption of all first premolars. premolar when removed [1, 2, 7, 44].
Stage IV: (Extraction of all first premolars after 7-8 months).
It provides space for canines and stimulates eruption of Enucleation
canines. There are times when there is unilateral loss of deciduous
canine, in such cases the other deciduous canine is extracted
In short and the Ist premolar is enucleated Enucleation has been
Step I ----------- II ----------- III ------------ IV defined as surgical removal of unerupted teeth usually
Points to be considered when handling a case in mixed premolar to minimize crowding. Most common disadvantage
dentition: (Warren Mayne‟s four principles) are loss of buccal or lingual cortical plates of bone or clefting
Incisor liability on an average is 7.6mm in maxillary. 6mm in associated with incomplete closure of extracted site [1, 3, 44].
mandibular.
Interdental spacing of 0.10mm in maxilla – avg 4mm 0.6mm Advantages of enucleation
in mandible – avg 3mm. Fewer visits to the orthodontics therefore decrease in trauma
Intercanine width increased in mandible upto 9 years for male and emotional disturbance. Fewer followup visits. In
and female it increases by average 3mm. In maxilla it mandibular arch 3 usually erupts before 4. So if it is found
increases upto 12 years in female and 16 years in male. It that the 3 is erupting labially then premolar may be
amounts to 4.5mm. enucleated. (Diagnosis for 3 erupting labially-gingival
Permanent incisors erupt labial to primary incisors by 2.2mm recession of anterior and canine bulge on labial surface). In
in maxilla and by 1.3mm in mandible. severe maxillary anterior crowding and excessive protrusion,
Thus, to overcome problems associated with unfavourable enucleation provides space for retraction of 1 and 2 proper
eruption sequences and to counteract varying degrees of eruption of 3.
dentoalveolar disproportions many extraction sequences have Retraction of 3 easier in crowded high angle cases,
been suggested: enucleation especially of 5 causes mesial migration of
a) C------ D ---- 4 posterior segment [46, 47, 48]. Figure 7
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Class I: Malocclusion with premature loss of a malocclusion at early mixed dentition period by extracting
mandibular deciduous canine certain primary and permanent teeth, and then guiding the
Class I malocclusion with premature loss of a mandibular eruption of remaining permanent teeth into the best possible
deciduous canine will result in midline shift, when the arch occlusion by using the physiologic eruptive forces and the
length discrepancy is 5-10 mm/arch, then the remaining existing normal neuromuscular balance. By doing so, the
deciduous canines should be extracted as the deciduous first extent and the need of corrective orthodontic treatment at a
molars are extracted next, if the first premolar have their roots later stage can be minimized.
more than half formed. If the roots of the first premolars are
not developed more than half, then extractions of the References
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