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Extraction Planning in Orthodontics

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 JCDP

10.5005/jp-journals-10024-2308
Extraction Planning in Orthodontics
Review article

Extraction Planning in Orthodontics

1
Mustafa Harith Al-Ani, 2Adil Osman Mageet

ABSTRACT Keywords: Crowding, Extraction of teeth, Hypodontia, Long-

term stability, Supernumerary.
Introduction: Planning extraction of teeth for orthodontic
treatment is one of the challenging factors for successful How to cite this article: Al-Ani MH, Mageet AO. Extraction Planning
functional and esthetic orthodontic results and for the long- in Orthodontics. J Contemp Dent Pract 2018;19(5):623-627.
term stability.
Source of support: Nil
Aim: The aim of this study is to document possible extraction
guidelines for planning of orthodontic treatment for space defi- Conflict of interest: None
ciency cases related to excess tooth material.
Results: The guidelines are written as patterns to facilitate the INTRODUCTION
decision of extraction of teeth for class I, class II division 1,
class II division 2, and class III malocclusions, for crowding, The main goal of orthodontic treatment is to obtain a
overjet reduction, or correcting the buccal segment relationship. normal relationship of the teeth with facial structures.
The decision for extraction of teeth for orthodontic treatment is Angle1 emphasized that the preservation of all dental
enforced by the oral hygiene, carious teeth, periodontal involve-
units was necessary to achieve facial balance.2 However,
ment, impacted teeth, supernumeraries, hypodontia, or for
orthognathic purposes. Also, planning the decision for accurate there are soft tissue constraints that limit the amount of
extraction pattern is the main factor in the success of the orth- alteration that can be performed orthodontically, which
odontic treatment and for the long-term stability of the results. necessitates the need for extraction.3
Conclusion: Orthodontic tooth extraction should always be The controversies regarding whether to extract or not
planned with consideration of the width and length of the face, that has been occurring for many years were often linked
the oral hygiene, carious activity, periodontal involvement, to personal preferences rather than scientific criteria.4
malformed crowns, length and health of the root of the teeth,
prognosis of impacted teeth, supernumeraries, and hypodontia.
Extractions in orthodontics were reintroduced scien-
tifically in 1930s and with the advent of Begg’s technique
Clinical significance: Accurate diagnosis and treatment plan-
reached its peak in 1960s. Different extraction protocols
ning following orthodontic extraction guidelines lead to a long-
term stability of the corrected results. have been followed for successful orthodontic treatment5
and accordingly in this study the need for extraction has
been elaborated.
1
Department of Orthodontics, Mageet Orthodontic Training Extraction of specific teeth is required in different
Centre, Khartoum, Sudan types of malocclusions, and the decision to extract
2
Department of Orthodontics, Mohammed Bin Rashid University depends on the patient’s medical history, the attitude
of Medicine and Health Sciences, Hamdan Bin Mohammed to treatment, oral hygiene, caries rate, and the quality
College of Dental Medicine, Dubai, United Arab Emirates
Department of Orthodontics, Mageet Orthodontic Training of teeth.6
Centre, Khartoum, Sudan; Department of Orthodontics, Faculty The aim of this study is to provide guidelines or pro-
of Dentistry, University of Gezira, Wad Madani, Sudan tocols of when to extract and what to extract in cases of
Corresponding Author: Adil Osman Mageet, Department of class I, class II/1, class II/2, and class III malocclusion.
Orthodontics, Mohammed Bin Rashid University of Medicine There are many factors that enforce extraction of teeth
and Health Sciences, Hamdan Bin Mohammed College of
for orthodontic treatment: Increased tooth size in relation
Dental Medicine, Dubai, United Arab Emirates; Department of
Orthodontics, Mageet Orthodontic Training Centre, Khartoum to the arch size (crowding), supernumeraries, hypodon-
Sudan, Department of Orthodontics, Faculty of Dentistry, University tia (if decided to close the space, may need extraction),
of Gezira, Wad Madani, Sudan, Phone: +971553378730, e-mail: carious teeth, increased overjet, open bite cases, impacted
adil.mageet@MBRU.ac.ae
teeth, camouflage orthodontic treatment, correction of the
The Journal of Contemporary Dental Practice, May 2018;19(5):623-627 623
Mustafa Harith Al-Ani, Adil Osman Mageet

buccal segment, malformed teeth, periodontally involved relationship, then an attempt should be made to preserve
teeth, orthognathic surgery, cleft lip, and palate. the first permanent molar until the second molar erupts.
A Nance is used to enforce the anchorage. Extraction of
Guidelines for Extraction in Class I Malocclusion all first molars is advocated in these conditions: minimum
space requirement needed with absolute no change in
Class I malocclusion is defined by the British Standard
profile, to correct anterior crowding or mild proclination;
institute in year 1983 by its incisor relationship, which is
grossly decayed/periodontally compromised molar with
the lower incisal edge that lies on or below the cingulum
poor prognosis; impacted molar.11
plateau of the palatal surface of the upper incisors. Its
Extraction of all first permanent molars should be
incidence among the Caucasian population was found
timed at 10 years of age, bifurcation of the second perma-
to be the highest among other types of malocclusion
nent molars just formed and presence of the third molars
with 60% according to Todd and Dodd, whereas in the
(Table 1, pattern 3).
Sudanese population it was found to be 49%,7 which
Extraction of all second permanent molars is indicated
is still highest among the other malocclusions but less
in relieving of possible impaction of second premolar due
compared with Caucasians.
to mesial drift of first molar occurring after premature
Treatment of class I with crowding has several dif-
extraction of deciduous second molar; severely carious,
ferent modalities: interproximal reduction (stripping),
rotated, or ectopically erupted second permanent molars.
expansion, derotation, uprighting, distalization, and
Extraction allows eruption of third molar (keeping in
extraction.
mind their favorable position). This will help to prevent
Table 1 simplifies and briefs the options of extraction
and relieve minor lower incisor crowding sometimes,
for general dentist, orthodontic residents, and specialists.
also will help in closing an anterior open bite; impacted
Extraction of all first premolars is usually indicated
permanent second molar against the first permanent
in moderate to severe crowding in the labial segment to molar;11 to distalize the first permanent molars to correct
create space for relieving of crowding. It is the common- buccal segment relationship. Avoid this pattern of extrac-
est pattern of extraction done by the orthodontist, as it tion in cases where there is missing third molars (Table 1,
is cantered between the anterior and posterior region of pattern 4).
the jaw, and it provides good anchorage in the posterior Extraction of right upper and lower first premolars
region to retract the six anterior teeth.8 In case one of and left upper and lower second premolars (or vice-versa),
the second premolars is carious, consider leaving the extraction of one side upper and lower first premolars
neighboring first premolar with anchorage enforcement with extraction of upper and lower first permanent
(Table 1, pattern 1). molars on the opposite side and extraction of one side
Extraction of all second premolars is usually indicated upper and lower second premolars with extraction of
in grossly carious, largely filled, or periodontally com- upper and lower first permanent molar on the opposite
promised second premolars and first premolars in good side. It is indicated that symmetrical extraction cannot
condition; moderate crowding in the labial segment and a be done due to poor prognosis of one or more teeth in
degree of crowding in the posterior region; anterior open different sides; for example, badly carious first premolar
bite, as extraction of second premolar helps in deepening on the right and another badly carious second premolar
the bite and for centerline correction. on the left. This enforces the extraction choice (Table 1,
It is preferred over first premolar extraction if the facial pattern 5).
profile is wanted to remain unchanged.9 In case one of the Extraction of lower second premolars in case of
first premolars is carious, consider leaving the neighbor- hypodontia of upper lateral incisors: This extraction
ing second premolar (Table 1, pattern 2). pattern is indicated when upper lateral incisors are
Molar extraction is not a recent practice. It was first missing or poor prognosis peg-shaped lateral. So they
introduced in 1939 by Chapin.10 First permanent molars will be extracted with presence of crowding in upper and
are extracted in case of poor prognosis, such as presence lower jaw. Tooth of choice to be extracted in the lower arch
of large restorations, pulpal necrosis, or severe hypopla- is the second premolar, because usually molar relation
sia. If space is required to correct the incisal or canine will be class II/1 and class II/2 unit, which is not a stable

Table 1: Patterns of extraction for class I malocclusion

Class I Patterns
1 2 3 4 5 6 7
4 4 5 5 6 6 7 7 4 5 4 6 5 6 2 2
4 4 5 5 6 6 7 7 4 5 4 6 5 6 5 5 1 1

624
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Extraction Planning in Orthodontics

occlusion. Extraction of lower second premolars will help and lower crowded arches. According to Fink and Smith,
to correct this relation to class I (Table 1, pattern 6). treatment is increased by 0.9 months for each extracted
Extraction of lower left or right central incisor is rarely premolar, thus this should be taken into consideration in
carried out and indicated in severely malpositioned the treatment planning14 (Table 2, pattern 1).
incisor excluded from the arch with good buccal segment Extraction of maxillary first premolars and mandibu-
relationship. Poor prognosis in case of trauma, caries, or lar second premolars is usually the extraction of choice
bone loss. Lower canines are severely distally inclined in the management of increased overjet associated with
and lower incisor is fanned. Most upright incisor will be a class I or mild class II skeletal pattern with moderately
extracted, so others will be tipped into position11 (Table 1, crowded arches. This tends to favor forward movement
pattern 7). of the lower molar to aid in the correction of the molar
relationship and retraction of the upper labial segment15
Guideline for Extraction in Class II Division 1 (Table 2, pattern 2).
Malocclusion When treating class II in the absence of crowding
Class II is defined by the British Standard Institute as with extraction of upper first premolars, the anterior
the lower incisor edges lying posterior to the cingulum segment of the upper arch is distalized to the extent of
plateau of the upper incisors. In cases of class II division 1 a premolar width (7 mm) so that cuspids can establish
malocclusion, there is increase in the overjet and the upper a class I relationship, while molars correct to class II full
central incisors are usually proclined.12 unit16 (Table 2, pattern 3).
Class II division 1 is considered to affect approxi- Extraction of maxillary first permanent molars only
mately 15 to 20% of Caucasians, and around 38% of is indicated in cases of badly decayed first molars and
Sudanese population, while class II division 2 affects severe crowding in the upper arch with mild crowding
approximately 10% of the Caucasian and 3% of the in the lower arch. Also in cases where there are ectopic
Sudanese population.7 maxillary canines, care should be taken to wait till the
Treatment of class II has several different modalities: eruption of the maxillary second permanent molars, then
growth modification, orthodontic camouflage, surgical a Nance appliance is used to enforce the anchorage.
correction. Removal of second permanent molars for correction
In this study we will be concerned of providing a of class II division 117-19 is suggested in case of excessive
guideline or protocol of when to extract and what to buccal inclination of the incisors, no diastema, minimal
extract in cases of class II division 1 incisor relationship overjet, presence of conveniently positioned and shaped
malocclusion. third molars, patients with a dolichocephalic facial
Table 2 presents class II division 1 to simplify and brief pattern, a tendency toward vertical growth, and the need
the options of extraction in class II division 1. for first permanent molar retraction. Extraction is recom-
Extraction of first premolars is considered to be one mended to decrease the likelihood of open bites and in
of the most commonly extracted teeth in orthodontics cases of existing pathologies, such as buccal eruption,
around 59%, followed by second premolars 13% and crown or root anomalies, caries or extensive restorations,
permanent molars 19% (1st permanent molars 12% and and enamel defects20 (Table 2, pattern 3).
2nd permanent molars 7%). Only 1% extracted permanent The best age to assess the third molars is between 12
incisors.13 and 14 years of age when their crowns are almost com-
The high percentage of first premolar extraction is pletely calcified and their position relative to the second
thought to be related to their position in the arch and the molar has been established. This is usually assessed
timing of their eruption. They are often ideal in the relief radiographically.21-24
of anterior and posterior crowding. However, each case Second permanent molar extraction for the correc-
is treated according to its need. tion of class II division 1 malocclusions often streamlines
Extraction of all first premolars is usually indicated therapy and significantly shortens treatment time by
in the management of increased overjet associated with a making first molar distalization easier and faster23-25
class I or mild class II skeletal pattern with severe upper (Table 2, pattern 3).

Table 2: Patterns of extraction for class II division 1 malocclusion

Class II/1 Patterns
1 2 3 4
4 4 4 4 4 4 6 6 7 7 2 2 2 2
4 4 5 5 5 5

The Journal of Contemporary Dental Practice, May 2018;19(5):623-627 625

Mustafa Harith Al-Ani, Adil Osman Mageet

Sometimes in increased overjet with peg laterals, Extraction of upper and lower second premolars is
removal of the deformed teeth is advised to correct preferred to first premolars in cases of severe crowding
the overjet (Table 2, pattern 3). In cases of congenitally to prevent the excessive movement of the lower incisors
missing upper lateral incisors or if they are peg shaped, lingually, which leads to deepening of the bite15 (Fig. 1).
extraction is preferred with lower second premolars,
closure of the space with upper canines, and correcting Guideline for Extraction in Class III Malocclusion
the buccal segment to class I (Table 2, pattern 4). The British Standard definition of class III incisor rela-
tionship includes those malocclusion where the lower
Guideline for Extraction in Class II Division 2
incisor edge occludes anterior to the cingulum plateau
Malocclusion
of the upper incisors.
Class II division 2 is defined as when the upper central Class III malocclusion affects around 3% of Caucasian,
incisors are retroclined and the laterals are proclined, 10% of Sudanese sample.7
or when all upper incisors are retroclined. The overjet is Treatment of class III has several different modalities:
usually minimal but could be increased.12 A recent study • Early orthopedic treatment (rapid palatal expansion
elaborated the definition as class II division 2a for the + face mask);
retroclination of the upper incisor, either the central or all • Orthodontic camouflage (extraction/nonextraction);
incisors with decreased overjet and class II division 2b for • Orthognathic surgery.
the retroclination of upper incisors with increased overjet.26 In this study, we will be concerned about providing
Class II division 2 is considered to affect approxi- a guideline or protocol of when to extract and what to
mately 10% of the Caucasian population and around 3% extract in class III malocclusion cases (Table 3).
of the Sudanese population.7,15 The extraction pattern for class III malocclusion could
When treating class II division 2 cases, it is best to be of either camouflage or orthognathic surgery.
avoid extraction. If crowding is marked, extractions will The extraction of choice for camouflage is extraction of
be required15 (Fig. 1). lower first premolars and upper second premolars. This
Extraction in the upper buccal segment with distaliza- is considered to resolve large mandibular crowding or
tion is beneficial in cases where the incisor relationship no crowding but edge-to-edge incisor relationship, and
needs correction and relief of crowding without affect- include significant tipping of mandibular arch. Maxillary
ing the overbite.14 It could also be used to correct buccal arch has no or mild crowding (Table 3, pattern 1).
segment crowding in cases of class II division 2. As most The second pattern is to extract one central incisor
of class II/2 are low-angle cases, no extraction is advised either right or left. It is the tooth of choice in situations
and distalization or stripping is preferred. where crowding is not large or situation of Bolton dis-
If there is crowding which cannot be solved by these crepancy.27 The only disadvantage could be of upper/
methods, then extraction is advocated, but when extrac- lower midline mismatch and the need for permanent rigid
tion is decided, upper and lower second premolars are lingual retainer as mandibular arch with three incisors
preferred, while some other cases benefit from extraction has a tendency for lingual collapse and deep bite (Table 3,
of the second permanent molars and distalization with a pattern 2).
Nudger and headgear. Extraction of all first premolar is carried out some-
times in severe crowding or in cases of class III compli-
cated with anterior open bite (Table 3, 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 crowd-
ing and vertical growth, as well as to attain class I molar
relationship28 (Table 3, pattern 4).
In cases where the one side is a class I and the other
Fig. 1: Patterns of extraction for class II division 2 malocclusion is class III, extraction of either first premolar/first

Table 3: Patterns of extraction for class III malocclusion

Class III Patterns
1 2 3 4 5 6
5 5 4 4 6 6 5 4 5 6 4 4
4 4 1 4 4 6 6 4 4 4 6 5 5

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Extraction Planning in Orthodontics

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