A DIFFERENT APPROACH TO EXTRACTION

PAUL V. REID, D.D.S., M.S., PHILADELPHIA, PA.

HEN a subject is chosen rather than assigned, an explanation is in order.

W For a good many years, the subject of extraction (particularly the extrac-
tion of atypical units) in orthodontic treatment has been of special interest to
me. Having arrived at the inevitable but unenviable stage where one finds
second-generation patients constituting an increasingly large proportion of
his practice, it is enlightening to look back over a sizable number of failures
and realize that probably many of them were the result of not having removed
teeth. At the same time, one can ponder the rather remarkable switch in the
attitude of a segment of the profession toward extraction in the last fifteen
years. The suspicion remains that, while the retention of a full ‘complement
of teeth is simply not possible in every case, neither is the removal of fout
premolars in the moderately crowded case the panacea which wishful thinking
would make it. In hope that a less drastic reduction in tooth structure might
be the answer to handling a certain group of cases, this article will consider a
few substitutions for the currently conventional mult.iple premolar extraction
and suggest a different approach t,o diagnosis.
No one attends a meeting, particularly a meeting held in such delightful
surroundings as this, for the purpose of changing his philosophy of treatment;
therefore, no attempt will be made to do other than outline a few alternative
courses to follow which occasionally might apply to the treatment of in-
dividual problem cases that do not quite seem to fit the usual extraction
pattern.
To justify an article with such an objective, it is necessa,ry to point out
some of the shortcomings of premolar removal in such wholesale lots as now
occurs. In true disharmony cases there can be no disagreement and the re-
duction of that amount of tooth structure necessary to produce structural
balance is required. But as the lack of supporting bone, when gauged by any
accepted means, be it cephalometric appraisal or cast sectioning, becomes less
marked and approaches more closely the adequate amount, then removing
some 28 mm. of tooth material becomes a radical procedure. For one thing,
it tends to increase the overbite; second, it requires extensive root movement
to close the spaces; and, most important of all, it is difficult to maintain con-
tacts in the arch and avoid eventual reopening of the spaces. The spaces are
Presented before the Southern Society of Orthodontists, White Sulphur Springs, Virginia,
Aug. 20. 1956.
334
Volume 43 A DTFFERENT APPROACH TO EXTR+TION 335
Number 5

especially inclined to reopen if the premolars are removed as soon as they

erupt and before the prepubertal growth spurt has changed the picture
entirely.
As a partia.1 example, the casts of a dental student’s mouth shown in Fig.
1 reveal a normal occlusion on the right side and a considerable amount of
crowding on the left. This is more pronounced in the maxilla. Following
the Tweed philosophy an orthodontist removed four first premolars and, with
skillful edgewise treatment, produced an apparently satisfactory result.

Fig. l.-Reopening of space at extraction site in the upper right quadrant with loss of oc-
clusal contact two years after retention was discontinued.

Photographs taken at the present time, two years after retention was sup-
posedly completed, reveal what has happened to the right side. A sizable
space has opened at the extraction site and the second premolar is out of oc-
clusion. Rather than disturb an occlusion as good as this was on one side, it
would seem that extraction of the first premolar on the upper left and align-
ment, of the upper incisors, followed by a reappraisal of the condition at that
time to determine whether the asymmetry thus produced was objectionable,
would have been a better course to follow. With such a concentration of
 336 IIEII) Am. J. Orthodontics
May, 1957

crowding in the upper left lateral incisor area, I doubt that the midline would
have shifted to a noticeable degree ; if not, a lower incisor could then have been
removed and the lower anterior teeth realigned without disturbing the original
setup on the right. Treatment time would have been reduced and, from the
standpoint of oral health, the patient would have been better off.
How important are these drawbacks to removing four premolars? From
the periodontal standpoint, failure to reduce the deep overbite, close the spaces
efficiently, and maintain tooth contacts in the arch is fraught with more
potential danger to dental health than residual or recurring crowding, which
is the usual result of over-conservatism in treating crowded cases. But while
the patient is well aware of what happens to anterior tooth alignment, he
remains blissfully unaware of what occurs in the rest of the mouth. As a
result, he does not return to the orthodontist, who may never discover that the
end of the retention period marked the beginning of relapse. The exact in-
cidence of these relapses is not known. Our periodontal department at the
University of Pennsylvania would like to conduct such a study of the 20- to
30-year-old group of posttreated orthodontic patients. Actually the practice
of removing premolars in such a large percentage of cases has not been in
vogue long enough to produce statistics on what happens to the soft structures
years later. However, the fact that most of the men who have been in practice
for more than twenty-five years have always been willing to extract teeth
when they felt it necessary and yet have never become so satisfied with the
results that they have swung violently over in that direction is rather eloquent
evidence that extractions, in the long run, have drawbacks.
It is necessary, however, to be certain that one’s antipathy toward this
type of extraction does not stem from a lack of skill in handling appliances
rather than from opposition to the principle involved. I think, rather, that the
reverse is true-that too much confidence in the ability of modern multiple-
band appliances to close spaces leads to overstepping the limits of the case in
arriving at a diagnosis.
In recent years I have watched the reactions of graduate students to
clinical experience with various philosophies of treatment. It would seem
that they are very likely to find the available evidence, as gathered from the
limited numbers of cases they see in the clinic? weighing heavily in favor of
extraction as opposed to nonextraction in the moderately crowded case. As
examples of this available evidence, let us examine two cases treated in our
clinic.
CASE 1 (FIG. 2).-The patient was a girl, aged 12 years, with no significant hereditary
background. Her facial development was within one standard deviation from the normal
for her age, except for a variance of two standard deviations in the porion-incision figure,
which is a reflection of incisor protrusion. Her facial pattern, as noted also in the cephalo-
gram, is not a bad one. The overjet is aggravated by the retained deciduous canines. With
this favorable growth picture, the case was treated without extraction and a rather satis-
factory result was obtained.
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 337
Number 5

Fig. t.-Nonextraction case. Casts and cephalograms before and after treatment. Treatment
time required was three years.
338 KEII) Am. J. Orthodontica
May. 1957

CASE 2 (FIG. 3).-A girl, aged 11 years 6 months, presented a different but entirely
adequate growth pattern with no marked discrepancies or deficiencies. Her profile in the
cephalogram is good. Four premolars were removed. The result is fine, possibly less open
to criticism than the first.

The student knows only this much about the two results. Both were
obtained with the same type of appliance. The first case was under active
treatment for exactly three years; the lower incisors have a slightly greater
procumbency now and therefore may show a marked tendency to relapse.
Case 2, on the other hand, was completed in one and one-half years; the in-
cisors are upright, the spaces are closed, and the retention problem apparently
will be simple. Esthetically, there is little to choose between the two results
There is no way of knowing the eventual outcome of the two cases. Main-
tenance of space closure may be as much of a problem in one asa tendency
to collapse is in the other. To the graduate student extractions presented by
far the simpler and more inviting method of attack. Actually, when the
student was reporting this second case in a seminar session after treatment was
completed, he used an expression which unconsciously reflects the way many
orthodontists actually feel. He had reviewed the examination findings and
read the very favorable report from the Growth Center, where Dr. Wilton
M. Krogman does preliminary studies on all the clinic patients, and then
concluded the case analysis wit,h this statement : “. . . and so we removed
four bicuspids. ”
This understandable inclination toward extraction is reinforced by read-
ing the preponderance of articles in the journals emphasizing cephalometric
diagnosis almost to the exclusion of considering etiology or studying intraoral
and lateral plate x-ray pictures, and relegatin, v the patient himself to a sec-
ondary role. The delusion that a diagnosis can be made mathematically in the
patient’s absence is then complete In many cases the diagnosis calls for
extraction and extraction, in turn, means the routine removal of four pre-
molars. This decision is final and, unfortunately, irreversible.
Actually, most of us (not just students) think of extraction as meaning
just this-the removal of four yremolars. Substantiating this is Dr. C. Edward
Martinek’s interesting article in the April, 1956, issue of the AMERICAN JOUR-
NAL OF ORTHODONTICS, in which he appraised five consecutive cases in his own
practice on the basis of four common methods of analysis used to aid in decid-
ing about the adequacy of supporting bone for the existing tooth structure. Of
the fire cases, one was obviously a disharmony case and one was very definitely
a nonextraction case, whereas in the other three the results of this multiple
analysis were neither conclusive nor uniform. In all four of the analyses, how-
ever, the choice was only between retention of the full complement of teeth
or removal of these same four units. That the four analyses did not concur is
no sign that one method was superior to another as an aid in diagnosis; it is
merely indicative of the limitations of any method when applied to a border-
line case.
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 339
Number 5

Fig. 3.-Four-premolar extraction case. Casts and cephalograms before and after treatment.
Treatment time required was eighteen months.
340

If extraction does have this one meaning in orthodontics, it still does not
particularly matter whether one’s attitude t,oward it is radical or conservative.
He must somewhere establish a sharp line of demarcation between what does
and what does not constit,ute an extraction case. Then, if one accept,s the
hypothesis that the extraction of four prcmolars does hart certain drawbarks
and that overconservatism in rcta.ining tepth also invites failure, thrsc very
shortcomings are most pronouncctl near this arbitra.ry line or borclerlinc zon(~
whcrc the ratio of support,ing bone to tooth structure is more nearly atleqnat(~.
It might be of some value to ~vcryonc, most. certainly to t,hc youugcr rnri~
st,arting out in this field, to have recourse to other methods of treating thcsc
bordcrlinc cases which present, particular difficulties in diagnosis. If one ad-
mits that at times neither of the conventional methods leads to caompletely
satisfactory results, then a search for an alternative course becomes worth
while. A completely new viewpoint in diagnosis is imperative in seeking a
solution. There is an analogy in the old brain tea.ser which all of you ma?
hart seen :

The nine circles arc to be connected with no more than four straight lines,
drawn without removing t,hc pencil from the paper. Until one discards the
self-imposed limitations of staying within the square, it cannot be done, and
yet t,he solution becomes obvious the minute one crosses this boundary:

A still further lack of inhibited thought suggests a third, and possibly still
not ultimate, solution :
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 341
Number 5

In orthodontics this constricting and self-imposed boundary can be

bIW ached by breaking away from the aforementioned tendency t,o consildcr
extr *action as always meaning four premolar-s and by determining, instc vld.

Fig. 4.--Case involving congenitally missing maxillary lateral incisors. Result stable two
years out of retention.

exa ctly what the individual case requirements are in the way of space nee ded
befc 3re making a stereotyped diagnosis as to extraction. Often the extra r()om
neet ded would be ideally provided by the removal of part of a tooth in each
342

quadrant. Although this is rather beyond the realm of practicability, it is

often possible to achieve a similar result by rrmoving upper second molars
and a lower central incisor. Then, by t,he additional distal driving thus made
possible in the upper arch, ancl by closing of the incisor space below, these
“ half-size ’ ’ increments in room can be obtained. Most of us have removed
t,hese teeth with satisfactory results in many CRSCS. The cst,raction of teeth
ot.her t,han these, however, is much less common and, while applicable t,o a
limited number of cases, it is often a perfect solution to spf’cific problrtns.

Fig. 5.-Compromise result in accident case. The upper right lateral incisor has been
fitted with jacket crown. The upper left central incisor in the original had been replanted
and was exfoliated during treatment and replaced with a facing attached to a lingual arch.

There is plenty of precedent for doing this, however. Let us consider three
types of cases, for example, where the teeth are already missing at t,he time
t.he patient is first seen, either congenitally (Fig. 4), because of an accident
(Fig. 5), or as an aftermath of caries (Fig. 6). Faced with a sit,uation, not of
choice, we all manage to come up with remarkably satisfactory results which
require often the utmost in ingenuity and therapy and yet arc peculiarly
suited to the individual patient. Sometimes these are, at best,, compromises,
but often, from the standpoint of oral health and function, they are superior
to more conventional results. With these results as justiflc&tion, it is con-
ceivable that the removal of any tooth or combination of teeth in the mouth
may be the best solution to certain problems.
Without wishing to detract from the individual character of these atypical
extractions, I feel that it is worth while to point out types of conditions where
atypical extractions are likely to apply.
Volun1e 43 A DIFFERENT APPROACH TO EXTRACTION 343
Number 5

Fig. G.-Case involving loss of four flrst molars due to caries and of upper central incisor
in a fall. The incisor has been temporarily incorporated in a retaining device.
344

JIAXILLARY SECOND JIOLARS

In order even to consider the removal of upper second molars, the first IY-
quirement is x-ray evidence of third molars that are adequate from the stand-
point of size and shape. When this has been verified, then extraction at this site
facilitates the distal driving of the first molar and the concomitant creation
of space mesial to it in those cases where the upper first molar occlusion is
either cusp to cusp or mesial to the lower first molar. This is a particularly
desirable procedure in deep overbite cases, as the invariable tendency is to-
ward a lessening of incisor overlap, quite in contrast to the opposite tendency
when premolars are removed. Other advantages are that it is easy then to
use as much or as little of the extra&ion space as the case requires rather than
being forced to close it completely, and the third molar erupts free of caries
after the most susceptible period in the patient’s life is over. This is, indeed,
one of the few instances in dentistry of a replacement excelling the original.

Fig. ‘I.-Favorable axial inclination of maxillary first molar when extraction of maxillary
second molar is being considered.

A favorable diagnostic factor is either visual or x-ray evidence of a mesial

axial inclination of the first molars (Fig. 7)) thus making possible distal
driving without tipping these teeth to an unstable degree. Contraindications
would go the reverse of this, that is: a distal axial inclination of the first,
molars, an already ideal Class I molar relationship, or a tendency toward an
open-bite which undoubtedly would be aggravated by this type of treat-
ment. When so many of our Class I and Class II cases are those with a mesial
drift of upper teeth en masse, it is not infrequently that we have six-yea1
molars already tipped forward to an unfavorable degree ; a diagnosis that calls
for an extraction mesial to them is putting a big load on appliances and ex-
pecting a lot in the way of bone growth to produce the necessary bodily movc-
ment of the largest tooth in the mouth. In this instance the remova of a
second molar would require more crown movement, but tipping a molar in-
volves fewer difficulties.
RIASDIBULAR 1NCISORS

Disharmony in maxillary and mandibular tooth size is a very real and

disturbing factor which interferes with achieving ideal results. Many un-
treated and otherwise normal occlusions are marred by either crowded lower
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 345
Number 5

incisors or an unsightly diastema above. If the disharmony is very marked,

the width of a single incisor below is often the approximate measure of this
discrepancy. Incisor extraction is also worth considering in cases where there
is one extremely malposed incisor, where one incisor has a badly receding
gingival crest, and particularly in those rather common instances where the
apical base is very constricted and the incisal crowns are badly flared as a
result. At times a canine will also be tipped distally so badly as to make
distal movement into a premolar extraction space impossible, whereas re-
moving the lateral incisor permits it. to move into vertical alignment (Fig. 8).

Fig. &-Case in which teeth were removed unilaterally. Extraction of the upper
right second premolar was balanced by removing the lower right lateral incisor. The decided
distal axial inclination of the canine was the decisive factor in the lower arch.

Incisor extraction tends to deepen the overbite and thus is contraindicated

in many instances for this reason alone. Ry far the most attract.ive feature
of removing a single incisor is the fact that it so often exactly fits the space
requirement in t,he lower arch, which many times is much less than in the
ma.xilla. Thus, removing one incisor will often offset the extraction of t,wo
premolars above in Class II cases. This is particularly true where the mandible
is already well positioned and removal of two lower premolars would requil;e
extensive movement of the distal segments. It also permit,s the alignment of the
remaining five anteriqr teeth without tipping them off the ridge.
UPPER INCISORS

Occasionally the removal of an upper lateral incisor or even a central

incisor is indicated. Every orthodontist has handled accident cases where,
following the loss of a central incisor, the patient has not been referred until
much of the space was lost. The lateral incisor was then centered in the
remaining space and jacketed and the rest of the occlusion was a.djusted. Con-
genitally missing lateral incisors arc also handled satisfactorily in many in-
stances by closing the space. This is done, not because it is always the
346 KEID

simplest procedure, but because in t,hese selected ca.ses, cithcr by requiring

less extensive treatment, by eliminating the need for a bridge, or by avoiding
extensive treatment in the lower arch, the patient’s best interests arc pro-
tected. With such cases in mind, it is logical to sacrifice an incisor intent,ionallp
when doing so allows the treatment to b(> confined more or less to one area of
the mouth without disturbing the rntirc occlusion which otherwise may be en-
tirely satisfactory. An example of this would hc a cast with a parbially blocked-
out maxillary canine which has a decided distal axial inclination of crown.

Fig. 9.-Lower labial arch of 0.030 precious metal with safety-pin loop at distal ends adjuste~i
to uprinht molars.

Extraction of t,he lat,eral incisor would allow for a simple tipping of the canine
into line. The resulting asymmetry may be as acceptable esthetically as though
a premolar had been removed, for the nnfavorable posit,ion of surh a canine
seldom permit,s enough root movement to match that of the one on t,he opposit,c
side.
LO\WR SECOND MOLARS

In a certain few marginal cases, the removal of lower second molars

serves much the same purpose as in the maxillary arch. When the distal
segments have drifted forward-possibly due to early loss of a deciduous
molar-it is much easier to move the first molar distally with the second molar
removed. Needless to say, the developmental path and inclination of the lower
third molar are not nearly so favorable in the mandible but, with judicious
selection of the case and with a practical method (Fig. 9) of tipping up the
third molar if necessary, this is a most welcome alternative to removing other
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 347
Number 5

units. As is the case with upper second molars, it allows the operator to utilize
the exact amount of space needed, favors the reduction of the overbite, and
eliminates the third molar impaction which might result if the conservative
course of treatment without extraction were followed.
Extraction of the aforementioned teeth will certainly find limited applica-
tion, but if one accepts the possibility of so doing, he has emerged from the con-
fines of the square of the old puzzle and opened for himself a new avenue of ap-
proach to dealing with borderline cases.
Having gone this far in breaking out of the bonds of conventional thinking,
it is easier to consider a second rerouting of one’s approach to diagnosis.
Most of us feel a compulsion to give an immediate. diagnosis of the patient’s
case and, even when this diagnosis involves a decision to remove teeth, we do
so. Urgency might require this in some branches of dentistry which deal with
pathologic conditions. Certainly this condition does not enter into our field.
In medicine, a physician might be hard pressed to give an immediate diagnosis
and, by not even attempting to do so when in doubt, he prevents many an
error in therapeutic measures. There is every reason to delay a decision about
removing teeth if there is doubt in one’s mind, as there so often is in the
borderline case. While this delay may wreak havoc with a concise treatment
plan, it permits the operator to begin preliminary treatment and to obtain
an idea of tissue reaction and patient cooperation. There can be no substit,ute
as a diagnostic aid for this ext,ra time spent observing the patient himself.
As a practical example of this, one might proceed as in the Class I case
shown in Fig. 10. The first major decision is whether or not to open up a space
for the congenitally missing upper right lateral incisor. This decision can be
made more easily after the incisors have been aligned and after the canine has
erupted so that the pabient,, as well as the operator, may pass upon the esthetics
of an upper arch with a lateral incisor missing. This alignment is easily
accomplished in a few months of treatment, and in this particular instance the
result at that time was mutually satisfactory. Rather than disturb the setup
on the left side of the mouth, it was decided to remove the lower right first pre-
molar and the central incisor; the progress photographs show how well the
unusal combination of missing teeth in the two arches balances.
In some Class II cases it may be a distinct help in treatment as well as
diagnosis to extract upper prcmolars and close the spaces before deciding up-
on the course to follow below. This provides undisturbed anchorage for the
preliminary stages of treatment and in many instances no extraction at all,
or the extraction of only one incisor, is needed below. It is not easy to
predict accurately just how stable or unstable lower anchorage may be; after
a few months of treatment it is no longer necessary to guess. Resisting the
natural pressure from patients to make immediate decisions about extractions
avoids many a needless extraction. In the case shown in Fig. 11, the growth
potential as evidenced after a few months of treatment was sufficient to in-
sure a successful result with a full complement of teeth.
348

Fig. IO.-Progress photographs of a case with a congenitally missing maxillary right

Iate :ral incisor in which a decision to remove a mandibular incisor and flrst premolar on the
San le side was made after flrst aligning the upper anterior teeth.

Fig. Il.-Class I malocclusion with completely blocked-out maxillary canines treated without
extraction. An immediate diagnosis would have called for extraction.
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 349
Number 5

APPLICATIONS IN TREATMENT

When such unorthodox procedures are followed in selected cases, the re-
sults may very well be termed compromises. In the usual sense of the word,
this denotes a result which is somewhat suboptimum but justified by mitigating
circumstances. Often more conventional treatment also produces a compromise
result but the compromise involves the patient’s best interests. Dr. Andrew F.
Jackson’ has ably supplied a standard by which to judge orthodontic results,
a standard which cites as necessary prerequisites for success (1) structural
balance, (2) functional efficiency, and (3) esthetic harmony.

Fig. 12.-Case 1. Class II case in which it proved necessary to extract maxillary second molars
to prevent relapse. Third molars have erupted unaided into ideal position at age 16.

The following cases may be judged on that basis as illustrating how well
the principles outlined apply in actual practice.
*Jackson, A. F. : The Art of Orthodontic Practice, AM. J. ORTHODONTICS 34: 383. 1948,
 REID

CASE L-Fig. 12 shows the casts of an g-year-old girl with a Class LC, Division 1
malocclusion, treated in two stages because of facial involvement. Treatment up to the stage
of retention at the completion of the second stage of the case was uneventful, but it was not
possible to maintain the corrected mesiodistal arch relationship despite the ose of intermaxillary
elastics at night in conjunction with a Hawley retainer and a lower labial arch. l’hctl uppe,
second molars were extracted and a fixed appliance was replaced for a six-month period of
retreatment. At the end of this time the upper lateral segments had been overdriven and rc-
tention was short and successful. The second set of casts was made three years aft,ei
the final appliances had been removed. Note the ideal alignment of the upper third molars
which erupted much ahead of the usual time.

Fig. Il.--Case 2. Previously treated case with stable result obtained by removing maxillary
second molars and lower left central incisor.

CASE 2.-Fig. 13 represents tho relapsed condition of a Class II, Division 1 case treated
several years previously without extraction. The boy was then 16 years of age. Because
the parents had moved to Philadelphia at the time active treatment was completed, retention
was unsupervised and consequently not adequat,e. Rather than risk retreatment without
extraction, in view of the previous tendency to instability, it seemed advisable to extract
Volume 43
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A DIFFERENT APPROACH TO EXTRACTION 351

upper second molars to correct the molar relationship and in the lower jaw, because of
the concentration of crowding in the anterior region, to remove just one central incisor.
Intraoral photographs show the result after a retreatment period of fourteen months.
The result has been maintained, and at least up until the time of his graduation from
college there had been no tendency toward relapse.

Fig. Il.-Case 3. Relapse of a treated Class II malocclusion, retreated after extraction

of maxillary second molars. Finished casts and photographs eighteen months after treat-
ment was completed show third molars in occlusion.

CASE 3 (FIG. 14) .-This is also a Class II, Division 1 case which had been treated pre-
viously. The original work apparently had produced a dual bite in spite of the use of extra-
oral anchorage. Although the boy could still bite forward with apparent ease, it could not
 REID

be assumed that he would ever do so regularly. The upper second molars were extracted
and the upper lateral segments overdriven. Finished casts and intraoral photographs show
the ideal and st,able interlocking several months after all hands ~vere removed.

E’ig. IS.-Case 4. Disharmony in size of upper and lower incisors. Treatment slmpliflc~l by
removing mandibular left central incisor.

CASE 4.-&4s a rather common example of disharmony

upper and lower in in&al width,
the casts in Fig. 15 exhibit a satisfactory posterior occlusion
and marked crowding in the
lower anterior region only. The lower left central incisor
was removed. When at all
feasible, it is preferable to extract a central incisor rather
than a lateral incisor in a dis-
harmony case such as this, even if it necessitates slightly
more t,ooth movement, because
it is usually somewhat narrower, thus favoring closurecomplete
of the space. The ap-
pliance used in this instance was a lower twin arch with all five anterior teeth banded and,
during most of the time, only an upper Hawley bite plane was u&d to decrease or at leant
to prevent any increase in the overbite. To gain additional resistance to tipping of the teeth
~hlIg”5” A DIFFERENT APPROACH TO EXTRACTION 353
”

adjacent to the extraction space, the bands are fitted at a slight angle to the long axis of these
two incisors. When the alignment of the five anterior teeth is completed, the bands are not
all removed at one time. The two canine bands are left on and the incisors are ligated to
the arch for one appointment. Then, after the canine bands have been removed, all five

Fig. 16.--Case 5. Disharmony again in size of upper and lower incisors compensated for by
extracting the lower left lateral incisor.

anterior teeth are ligated to the twin arch and intramaxillary elastic force is used to com-
plete the closure of the spaces. This is a routine which is followed in these cases because
of a tendency otherwise for the spaces left by the ten thicknesses of band material to con-
solidate at the extraction site. At times a canine-to-canine sectional labial arch is used as
a retainer.
 Fig. li.--Case 6. Malocclusion resulting from twinnf31 maxillary incisor treated as
though it wei-e a case with n unilateral congenitally missing lateral incisor. Treatment
time was ten months: no retention w&8 required.
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 355
Number 5

CASE 5 (FIG. 16).-This is similar to the previous case except that, since the primary
objective of treatment was to correct the labioversion of the lower left canine, it was deemed
more expedient to remove the lower left lateral incisor. Both of these cases, very simple in
nature, are shown merely to illustrate how well the width of one lower incisor approaches
the measure of the existing disharmony. It will be noted that the posterior occlusion is
no longer ideal but stability is obtained by equilibration.

CASE 6.-This case (Fig. 17) is unusual in that it presents a fused incisor in the upper
left quadrant. When the patient was 8 years of age, at which time the original models
were made, an attempt was made to separate the two halves of the fused tooth. This was
unsuccessful because of an anastomosis of the nerve canals at the root ends. Nothing was
done then for two years and the second set of casts shows the canine erupted in the space
where the lateral incisor had been. A very short period of treatment (ten months), with
only an upper twin arch most of the time, closed the space on the upper left side, and intra-
oral photographs taken a year apart after treatment was completed show that the result
is stable. No retention was required.

Fig. lS.-Case 7. Case in which upper and lower second molars on only the right side
were removed. Intraoral photographs flve years after treatment was completed.

CASE T.--The casts in Fig. 18 represent the end result of two years of orthodontic
treatment. By mutual consent, the parents and the orthodontist had agreed to discontinue
treatment. The patient was then 14 years of age. The slight overjet still present caused the
lower lip to curl under the upper incisors, and the lower incisors were far from straight.
Unilateral extraction of the upper and lower right second molars provided not only the re-
quired room in the lower arch, but made it possible to obtain a normal interlocking of the two
lateral segments and reduce the overjet. Treatment took thirteen months, but the second
photograph taken five years after treatment was finished seems to justify this unique method
of handling a problem case. The third molars are in functional occlusion without any
correction.
356 EEID Am. J. Orthodonti< cs
May, 195si

19.~-Case 8. Progress photographs of deep overbite case where four second molar
were extracted. Note change of position of third molars in roentgenograms.
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 357
Number 5

CASE 8 (FIG. 19).-The patient was a boy, aged 16 years. The casts show a Class II
molar relationship with a deep overbite. This boy’s older brother had been treated pre-
viously. Several years after retention had been discontinued in his case, some relapse due
to loss of expanded arch width in hoth jaws had occurred. At that time the four third molars
were extracted surgically and the case was retreated with fixed appliances followed by
a Kesling positioner. The result at present-two gears after the positioner was discon-
tinued-is good and apparently stable. With this experience in mind, treatment for the

Fig. 20.-Case 9. Class I malocclusion. Extraction of upper premolars balanced by removal

of one lower incisor.

younger brother was started with the stipulation that if, after a few months of active
treatment, it seemed advisable to extract teeth, the four second molars would be removed.
After three and one-half months of active treatment, it became apparent that, to obtain
room to align the lower anterior teeth without producing too much procumhency, there would
have to be some distal movement of the molars and premolars. This was the deciding
factor and, since any distal movement of the lower molars would necessitate that much
additional distal driving of the upper molars, all four second molars were extracted. The
position of the four third molars is shown in t,he x-my picture. Photographs taken eighteen
months later (with treatment still unfinished) show the corrected molar relationship, improved
anterior alignment, and a much rc~luccd anterior overbite. The upper third molars are in
place in perfect alignmcut aud rec*cut x-ray pictures show the lower third molars io a fnvorahle
position for early eruption. The delay in making a final decision to remove second molars
did not slow up treatment progress t,o any extent. It will be noted that the lower t,hird
molars are in a more upright position than the x-ray pictures taken at the time treatment
was started, and especially the ones takeu four years prior to that would lead one to ex-
pect.

Fig. Il.--Case 10. Borderline case with tendency toward an open-bite. Result obtained
by extracting ripper left flrst premolar and lower left central incisor shown six years out of
retention.

CASE 9 (FIG. 20).-The casts of the patient, a 13Ys-year-old girl, present a Class L
molar relationship with upper and lower anterior crowding. Since the patient was a small-
boned person, and because of hereditary fact.ors, this was apparently an extraction case.
It was decided that two upper teeth would Fe extracted at the start of treatment and the
spaces fairly well closed before extraction of lower teeth. The upper left first and the right
second premolars were selected because it was evident that more mesial movement of the
distal segment would be necessary on the right side. It is only logical to have the space
Volume 41
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A DIFFERENT APPROACH TO EXTRACTION 359

nearest to the teeth requiring the major movement. Six months later the lower right
central incisor was removed. Two factors entered into this decision: first, the loss of
that amount of tooth structure would be sufficient to obtain a correct positioning of the
remaining anterior teeth and, second, this presumably would cut down treatment time which
suddenly had become of extreme importance when the family received orders to an overseas
duty station. Whether the result is as satisfactory as if lower premolars had been re-
moved is subject to argument but, with no chance to supervise retention, this may be the
better choice for this one case. Esthetics are satisfactory and treatment, which took fourteen
months, barely met the deadline.

CASE 10 (FIG. 21).-This is the case of a girl, aged 15 years, with a slight amount of
anterior crowding in both arches. With so little vertical overbitr, conservative treatment with
out extraction, at least in my own opinion, is ruled out because of the tendency toward an
open-bite. Any degree of expansion would be likely to produce this complication. Taking
into account that the maxillary midline was slightly over to the right side, it was possible to
expect that, with only the upper left first premolar sacrificed, the anterior teeth could be
realigned with no increase in asymmetr>-, although it would merely be in the opposite
direction. Since this much could be observed after a very few months of treatment, the final
derision as to how to proceed from there on could be deferred. Since both dental arches were
fairly wide and basal bone was quite plentiful, it was hoped that the esthetic result aft,er the
initial extraction would justify not having to remove the remaining three first premolars, but
instead would balance the premolar loss above by one central incisor below. This was the
eventual course followecl. Treatment was short and the results six years after reten-
tion was discontinued show that, structurally, the case is in balance. Functionally, it is
satisfactory and, as for the esthetics, the patient is primarily the judge.

CASE 11 (FIG. 22).-This case was treated in the clinic by a graduate student. This
is another example of a delayed diagnosis. The reasoning was that, with the lack of room
in both arches, some extractions were likely to be necessary. The upper right lateral incisor
was so completely overlapped by the ion-er anterior teeth that correcting this relation
would be difficult. The lower arch form was good, but the right second premolar was
blocked out of line. Before any decision about extraction was made, the cross-bite of the
central incisors was first corrected. At this point the amount of room needed in the upper
arch could be more accurately gauged. After the parents had been given a complete explana-
tion of all the pros and cons, the upper right lateral incisor was extracted along with the
lower malposed premolar. Closing these small spaces was no problem; the original occlusion
on the left side was undisturbed and the result is comparable to a case involving a con-
genitally missing lateral incisor-not ideal but individually appropriate for t,his patient.

APPLICATION TO MINIMAL TREATMENT

In each of the foregoing cases, the treatment followed was a matter of choice.
Economic factors did not enter into the diagnosis. In these times, when our
Government is giving more and more attention to the health needs of the entire
population, it is essential for our profession to give some thought not only to
preventive orthodontics, but also to minimal treatment. The need for both of
these services is emphasized by contact with an orthodontic clinic where there
is an unbelievable demand for both. Cases which most need treatment are also
likely to require extraction. The atypical extractions outlined in this article
are ideally adaptable to minimal treatment, for in these cases structural
balance and function can be obtained in short order while the esthetic effect
must be judged by comparison, not wit,h the ideal but with what the patient
 Am. .I. Orthodontics
360 May. 1957

now has and might otherwise have to be content with. The cases which follow
illustrate the application of atypical extractions in the treatment of four dc-
serving youngsters for whom optimal care, eren in a clinic, was out of the
question.

Fig. 22.-Case 11. Class I malocclusion with anterior cross-bite. Casts before treat-
ment and after unilateral extraction of maxillary lateral incisor and mandibular second
premolar.

CASE L-The dental casts shown in Fig. 23 are those of a girl aged 11 years, with a
neutroclusion, an upper lateral incisor in linguoversion and completely overlapped by the lower
opponents, plus the complication of a twinned lower incisor and hypoplastic enamel. All that
was done was removal of the upper lingually posed incisor and closing of the slight space
thus created. This satisfied the structural and functional needs of the patient and actually
met her appearance requirements quite adequately.
Fig. “3.---B dinimal treatment involved removal of lingually locked incisor and closing of spat

Fig. 24.-Minimal treatment again involved compensating for a previously extracted mandib-
ular incisor with the sacrifice of maxillary right lateral incisor.
 CASE 2 (FIG. 24).-Economics again dictated procedure in dealing with this 12.year-old
girl’s problem. The molar relat,ion was normal. One lower incisor had been ext.racted by
her dentist because it was so far out of line. The upper right lateral incisor was badl>
rotated and, by extracting it. roon~ was provilletl for rotating the other three incisors
without extensive trcatrucnt and thcl missing toot11 in thca mantlil~ular arch WRS balanced.

Fig. 25.-Serial extraction and simple treatment, which involved removal of upper prenmlars
and lower left lateral incisor, produced functional result and very satisfactory esthetics.

CASE 3 (FIG. 25).-At the age of 8 this boy, as shown by the original casts, had two
upper lateral incisors and the lower left lateral incisor fairly well blocked out of line.
Primary treatment was instituted to obtain increased arch width, but it became apparent
after a few months that sticient room could not be made to accommodate a full comple-
ment ot’ teeth. Thus, the maxillary deciduous canines were extracted to allow the lateral
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A DIFFERENT APPROACH TO EXTRACTION 363

incisors to erupt. The comparative arch form of the original upper and the same arch at
the time when the lateral incisors had been aligned are shown in the center photographs.
This treatment took one year. Observation was so planned as to intercept and remove the
first premolars above as soon as they erupted. The lingually posed lower incisor was also
castraeted at this time and six months of twin arch therapy produced the results shown.
The face is well balanced and, esthetically and structurally, the denture is satisfactory.

Wig. 26.-Mandibular left lateral incisor was extracted in this case to balance extraction
of premolars in upper arch and shorten treatment time.

CASE 4 (FIG. M).-This is neutroclusion case in a boy, aged 13 years. Again circum-
stances dictated minimal treatment. The upper arch was narrow and supporting basal bone
did not seem adequate for retention of all the teeth. The upper first premolars and the
lower left lateral incisor were removed. Lower arch form, discounting the one incisor in
linguoversion, was almost ideal and practically no appliance therapy was needed. The upper
spaces were closed with a lingual arch and finger springs, followed by a twin arch and intra-
maxillary elastics. Although this did require seventeen months, appointments were widely
spaced and the treatment could aptly be termed minimal.

SUMMARY

The cases presented are fairly representative of the application of atypical

extractions in treatment. These cases have not been of any particular type, nor
would this therapy fit any type of malocclusion. It is only hoped that in an
364

Fig. Z7.-Gingival recession on lower incisor should influence drcision about extraction in
this ease.

2g.-Fate of impa&ed mandibular second molar when premolars were removed

in Clsf II malocclusion and the flrst molar was moved mesially. This possibility was over-
looked at the time the diagnosis was made.
Volume 43 A DIFFERENT APPROACH TO EXTRACTION 365
Number 5

occasional selected case where the retention of a full complement of teeth either
seems impossible or proves to be impossible, this undeniably individual selection
of teeth to remove will be weighed against conventional earmarking of pre-
molars and found more expedient.
This approach to the extraction phase of diagnosis will obviously lend it-
self to no popular philosophy of t,reatment. From my short teaching experi-
ence, I know that it will have none of t,he appeal that goes with t,he concise
step-by-step treatment planning that accompanies edgewise analysis of cases
involving extraction of four premolars. When the time comes that results
achieved always match expectation, there will be no need for as flexible an
outlook as has been presented here. Until that time, it may be not only help-
ful, but fundamental, to consider the individual aspects of every case as being
foes to conformity. With alternative units to consider for extraction, and com-
binations of them to be made to fit, special problems, and even latitude in the
timing of the decision to rxtract, there is less tendency to hurry into a final
diagnosis which, if it involves the loss of four teeth, may lead t,o failure. A
concept which does not allow for an individualistic approach can lead to such
easily avoidable errors as these.
In the first case (Fig. 27) the existing gingival recession around the lower
central incisor was overlooked. Since it was obviously an extraction case, four
premolars were removed. This patient was treated in our clinic at school and
t,he recession progressed during treatment to an alarming degree. Here is an
example of an individual factor which should have led to a different decision
as to the selection of extract,ion units in the mandibular arch. With noticeably
less crowding below than in the maxilla, removal of the one affected incisor
might easily have provided the necessary room and eliminated the periodontal
problem.
A similar adherence to routine was evident in the second instance (Fig. 28)
with its inevitable aftermath. Existence of the second molar impaction at the
time of diagnosis failed to influence the decision. As it happened, the first
molar was moved mesially during the process of closing premolar extraction
spaces in the lower arch and, unfortunately for the orthodontist involved, the
second x-ray picture was taken by the patient’s grandfather.
There was nothing unusua,l about either of these cases. The results ob-
tained would have been acceptable except for the specific factors which should
have been taken into account. As it was, these eases were fitted to the treat-
ment philosophy. In orthodontics this is the cardinal sin.
MEDICAL ARTS BTLKL