Topic of update

Extractions In Orthodontics:
An update
Morón Duelo, Rocío
Graduates in dentistry, 3rd year
residents Orthodontics Postgra-
duate Programme, Fundación Ji-
ménez Díaz University Hospital.
Marcianes Moreno, María
Graduates in dentistry, 3rd year
residents Orthodontics Postgra- Published in spanish Científica Dental Vol. 12. Nº 1. 2015
duate Programme, Fundación Ji- www.cientificadental.es
ménez Díaz University Hospital.
De la Cruz Fernández, Carmen ABSTRACT situation of each patient and never con-
sidered as a rigid scheme of general ap-
Graduates in dentistry, 3rd year
residents Orthodontics Postgra- The aim of this article is to review the plication.
duate Programme, Fundación Ji-
ménez Díaz University Hospital. current main criteria for tooth extrac-
Domínguez-Mompell Micó, tions in the prophylaxis and treatment of
Ramón
Graduates in dentistry, 3rd year
malocclusions and dentofacial deformi- KEYWORDS
residents Orthodontics Postgra- ties. Dental extractions are an essential
duate Programme, Fundación Ji- therapeutic weapon in the management Extractions; Malocclusion; Orthodontics;
ménez Díaz University Hospital.
of certain malocclusions. They are indi- Eruption guide; Facial aesthetics.
García-Camba Varela, Pablo
Dentist, Doctor in the UAM De- cated for obtaining arch space, improve-
partment of Medicine, Specialist ment of facial aesthetics and
in Orthodontics in Orthodontics
Unit and Lecturer in the Ortho- achievement of balanced occlusion,
dontics Graduate Programme, among others.
Fundación Jiménez Díaz Univer-
sity Hospital.
"Conventional" standards of therapeutic
Varela Morales, Margarita
Doctor of Medicine and Surgery, extractions correspond to different com-
Specialist in Orthodontics, Head binations of symmetrical extraction of
of Orthodontics Unit and Director
of the Orthodontics Graduate premolars; however, atypical extractions
Programme, Fundación Jiménez
Díaz University Hospital.
which do not follow a definite pattern are
becoming increasingly frequent. They are
Indexed in:
- IME
more common in adult patients and are
- IBECS performed for reasons related to the
- LATINDEX
- GOOGLE SCHOLAR pathology of the extracted tooth itself or
Correspondence address: to the demands of unconventional mal-
Rocío Morón Duelo occlusion treatment. Examples of atypi-
C/El Majuelo nº1 portal 4, 4ºA
28005 Madrid, Spain
cal extractions are that of a lower incisor
[email protected] with indications, contraindications and
Tel: 620477854
undesirable effects which are well de-
fined.
Received: 13 February 2014.
Accepted (or accepted for publication):
4 April 2014. Temporary teeth extractions may be per-
formed as part of an eruption guide pro-
gramme, which must be adapted to the

científica dental. vol 12 (special supplement) 2015. 32

 tions for extractions and the patterns of teeth to ex-
tract.

I. INDICATIONS FOR
EXTRACTION IN DENTISTRY
Therapeutic extractions in orthodontics are primarily
done for the following reasons:
Figure 1: A. Edward H Angle and B. Calvin S Case.
1. Achieving arch space: To correct negative osseo-
BACKGROUND dental discrepancy (DOD), which usually mani-
The need to perform extractions as part of the treat- fests as crowding.
ment plan for some malocclusions remains one of the 2. Facial aesthetics: To reduce dentoalveolar pro-
great controversies in orthodontics. trusion.
Since the dawn of the specialty, Angle passionately 3. Occlusion: To properly connect both arches in
defended the conservation of all teeth for perfect oc- normo-occlusion.
clusion. He eventually accepted the need to abandon
this ultraconservative position and to take into ac- 4. Stability: To better maintain the results achieved.
count the impact on the profile, stability and other
constraints, such as periodontal health and declared 5. Others: For example, periodontal health, dental
to have acted to maintain the complete dental provi- and medical pathology.
sion of some of his patients at all costs. On the other 1. Extractions and arch space: DOD
hand, Calvin Case, who could be considered a con-
temporary scientific adversary, advocated the use of One of the most important and common indications
permanent teeth extractions, if necessary, to success- for orthodontic extractions is the lack of space in the
fully resolve malocclusion (Figure 1). arch that usually manifests as more or less localised
crowding.
Since then, there have been swings in prevailing cur-
rents of opinion regarding therapeutic extractions in Achieving proper dental alignment in their bony bases
orthodontics. On the one hand, these movements requires consideration of the compromise between
have been based on the different fashions presiding the size of the teeth themselves and the size and shape
over facial aesthetics at different historical times; but of their bases within the framework of the dentofacial
also on the availability of therapeutic techniques and skeletal relationship for each patient. The orthodontist
instruments of varying scientific bases, replacing can act on the maxillomandibular skeleton well using
what were previously inevitable extractions for han- orthopaedic means in children, as well as in adoles-
dling certain malocclusions. Fundamental among cents with residual growth or with surgical care where
these was the introduction of the palatal arch bar by there is no such growth. In every case, the limits im-
Cetlin, distalisers, microscrews, and self-ligating posed by the individual maxillomandibular anatomy
bracket systems. must always be assessed when deciding whether a
malocclusion with negative DOD can be resolved con-
This review discusses the most relevant aspects sur- servatively or whether one must resort to extractions.
rounding the application of this important therapeu-
tic tool in orthodontics, in the light of information Some multibracket systems, particularly self-ligating,
found in the literature. We will focus on the indica- have entered the market declaring they are able to re-

33 científica dental. vol 12 (special supplement) 2015.

duce the need for extractions in a number of cases of buccal corridors. This change in tastes for greater fa-
negative osseodental discrepancy, where it would cial convexity is mainly for women and in Caucasians;
have been essential to remove teeth if conventional whereas in the male and in oriental races, the flat pro-
techniques had been applied. However, disputes in file is still considered more harmonious. Obviously,
this regard are very important. Many authors consider this is not the case in negroid races, one of whose
that these techniques only produce a dental overex- most characteristic features is precisely biprotrusion.
pansion of the arch which does not correspond to real
production of alveolar bone to neutralise the DOD, The greater tolerance to convexity in our environment
and instead could lead to an unacceptable weakening has naturally reduced the need for extractions due to
of the alveolar bone tables. biprotrusion and DOD. For example, Proffit performed
a study on the changes in the pattern of extractions
Distalisation devices to prevent extractions by mesial- in the treatment of malocclusions during the last 60
isation of the maxillary molars where there is a lack years. It showed that the frequency of extractions was
of space deserve a special mention. Distalising these around 30% for the years 1953 and 1993: 40 years
molars can lead to recovery of space in the arch that apart. However, interestingly, the analysis in 1968
could otherwise only be obtained by extracting pre- gave a result of 76%. The explanation given for this
molares7-10. high percentage was the trend at the time for remov-
ing all teeth outside of the arch. At present, this pro-
Mention must also be made of the unquestionable
portion is limited to 5%; 20% down on most studies1.
contribution that micro-implant development has
made in preventing many extractions; in fact, this is However, there are some facial features linked to ex-
one of its numerous indications. cessive convexity which are objectionable in any aes-
thetic framework and put a limit on the extraction
When there is a negative osseodental discrepancy due
option. One of those features is the hyperactivity of
to excess transverse dimensions in the teeth, it is fea-
the muscles of the chin associated with biprotrusion
sible to reduce this by a stripping technique. How-
which, in an effort to close the lips, gives the chin a
ever, one or more teeth will have to be removed in
kind of "golf ball" appearance.
many cases, even after reasonable expansion of the
arches. This method does not exclude extractions, but The positive effect on the profile of extracting the bi-
in many cases is complementary to them; i.e. achiev- cuspids in patients with a normal vertical dimension
ing a suitably wide arch is a goal in itself, which will or a little short and a marked biprotrusion, especially
not always guarantee that DOD extractions will be
if associated with crowding, is generally clear; thus,
avoided.
there is usually agreement among authors for its in-
2. Extractions and facial aesthetics dication1. This does not occur in the biprotrusive pa-
tients with a pattern of mandibular posterorotation
One of the main indications for orthodontic extrac- and dolicofacial growth. The aesthetic result in these
tions is to achieve a more harmonious profile in pa- patients of resolving biprotrusion with extractions is
tients with excessive facial convexity secondary to unpredictable, if not clearly wrong; so the clinician is
dental biprotrusion. It must be noted, in this regard, often faced with the choice of obtaining good occlu-
that the concept of the ideal profile has changed no- sion at the risk of worsening facial aesthetics, or not
tably throughout the last century6. Several decades altering the profile and accepting the limitations in the
ago, the ideal Caucasian profile was flat or even resolution of the malocclusion. Obviously, in cases
slightly biretrusive, with relatively thin lips; while in where the dentofacial deformity is more severe, or-
recent times more convex profiles have become more thognathic surgery allows for both goals, facial and oc-
popular with a marked lip relief and a wide smile with clusial.

científica dental. vol 12 (special supplement) 2015. 34

 If both have the same malocclusion,
which will be their treatment?

Treated by Theeth extraction

removing the first should be avoided
bicuspid

Figure 2: Patient A has a dentoalveolar biprotrusion with convex profile. Patient B has dentoalveolar biretrusion with concave profile.
If both have the same malocclusion with crowding, patient A should be treated by removing the first bicuspid, while teeth extraction should be avoided in
patient B if possible, due to potential undesirable effects in facial aesthetics.

A trait that also determines the indication for thera- and functional appliances may contribute to achieving
peutic extractions and the management of orthodon- this desired molar class I, linked to the normalisation
tic appliances in these cases is the presence of overbite of the skeletal relationship. When no residual growth
or open bite. Extractions tend to increase overbite, remains, apparatus specifically aimed at the normali-
which is positive when there is a tendency to open bite sation of occlusal relationships can be used. There are
and undesirable in patients with a deep bite. numerous molar distalisation devices to treat Class II
teeth7-9 and designs with microscrews for classes II, III
In short, the indication of therapeutic orthodontic ex- and open bites, for example10. However, it is often not
tractions is subject to multiple circumstances which possible to achieve the objective of the molar normal
need to be carefully assessed in the treatment plan. In occlusion, so extractions need to be resorted to for a
fact, an identical malocclusion will require a conserva- class I canine, and other aesthetic or periodontal goals,
tive or extractive approach depending precisely on a for example. As discussed below, these can be planned
rigorous evaluation of these circumstances. Figure 2 according to a typical pattern (class II upper premolars
outlines this unquestionable reality (Figure 2). and class III lower ones), or atypical patterns can be
used, depending on the circumstances of each case.
3. Extractions and normalising occlusion
4. Extractions and stability of results
Achieving a class I canine is not an objective to be
waived with a malocclusion; although in exceptional One of the key aspects in the success of orthodontic
circumstances limitations have to be accepted in this treatment is the stability of long-term results, which
regard, especially in adult patients. depends on certain parameters such as the interinci-
sive angle, overbite, overjet, appropriate transverse
However, although desirable, an Angle class I molar dimensions and good periodontal health. There is no
seems inessential for either oral or joint health. Nev- general agreement on the impact of therapeutic ex-
ertheless, the orthodontist usually tries to achieve it. tractions on the post-treatment stability of each of
When the patient is in growth, the use of orthopaedic these parameters. One of the advantages that have

35 científica dental. vol 12 (special supplement) 2015.

been claimed for extractions is that they promote 2. Atypical extractions
stability, both with overjet and crowding. However,
not all authors agree, and some view the possibilities In practice, they are very common and, although
of extractions with scepticism and say that, over they may be necessary in patients of all ages, their
time, the lower incisors tend to come together again, frequency has increased proportionally with the in-
regardless of the treatment modality: conservative corporation of adult orthodontic consultations. They
or not conservative1. Others point out that the key have multiple indications, whether related to the
issue is the proper location of the teeth relative to pathology of the extracted tooth itself or unconven-
the alveolar bone to maintain stability and periodon- tional malocclusion treatment demands. These ex-
tal health; such that the only thing that would ensure tractions are very commonly indicated in adult
stability would be obtaining a proper interincisive patients because, after a certain age, dental mutila-
angle (Figure 3). tions, periodontal disease and other conditions that
will affect the malocclusion treatment plan are a
One experience shared by orthodontists is that deep constant feature in our environment.
overbite in extraction cases tends to recur more than
Table II contains examples of reasons for unconven-
in cases where no extraction takes place12.
tional or atypical extractions. Particular atypical ex-
5. Extractions and intrinsic pathology tractions worth a mention are extraction of a lower
incisor and the first molars, so these are particularly
Sometimes, in planning the treatment of a malocclu- referred to from the orthodontic treatment point of
sion that could be treated without extractions, re- view34,35.
moval of one or more teeth is included simply
2.1 Extraction of a lower incisor
because they have intrinsic pathology or are peri-
odontally compromised. If ignored, this condition can The frequency of extraction of a lower incisor in or-
compromise medium- or long-term viability or hinder thodontic clinics is highly variable. Most authors put
the treatment of the malocclusion itself. At other the figure at 1.1-6% of all patients treated for mal-
times, it is the requirement of an interdisciplinary occlusion33,36. For example, Proffit in the 1950s
treatment where other experts make the decision to recorded the extraction of a lower incisor in 20% of
extract. The most common pathology in this sense is all malocclusive patients treated with extractions6.
partly periodontal (including recessions and severe
dehiscence) and partly pulpar of an infectious or trau- The main indications for extracting a lower incisor are:
matic nature. Although morphological abnormalities
- Malocclusion of Angle Class III, light – moderate,
and ectopic eruption are other reasons.
with little negative overjet or 0 overjet and de-
creased overbite.

II. PATTERNS OF TEETH This is the fundamental indication, but has the limi-
TO BE REMOVED IN tation of not properly resolving the molar and canine
ORTHODONTICS classes. Extracting a lower incisor involves a reduc-
tion in arch length and extrusion and retrusion of the
1. Conventional or typical patterns remaining lower incisors; thus increasing the over-
bite and overjet. As a result, extraction of a lower in-
Table I Shows the most common tooth extraction cisor is only recommended in patients with an Angle
patterns used and their main indications for treating Class III malocclusion to resolve mild to moderate an-
malocclusions. It is open to multiple qualifications terior crowding not accompanied by excessive over-
and exceptions but is basically an indicative scheme. bite or large negative overjet.

científica dental. vol 12 (special supplement) 2015. 36

 - Malocclusion of Angle Class I or II with Bolton dis- ancy excess or remodelling of the upper incisors in
crepancy upper discrepancy defect.
The extraction of a lower incisor may be indicated for Specifically in class II with Bolton discrepancy, the ex-
an increase in the transverse dimension of the lower
traction of a lower incisor may be combined with the
incisors (lower discrepancy excess), but also when
use of some distalisation mechanism, or with the ex-
the patient has microdontia, or even agenesis, of the
upper ones (upper discrepancy defect). In these traction of two upper bicuspids. Skeletal class II cases
cases, extraction of the lower incisor is considered can be treated with orthognathic surgery, with the
over other possible alternatives, as would be strip- extraction of a lower incisor possibly being part of a
ping in the anteroinferior sector for lower discrep- presurgical orthodontic treatment plan.

A B C

D E F

G H I

J K L

M N Ñ

O P
Figure 3: Patient with dentoalveolar biprotrusion treated by extracting first bicuspids. An improvement in the profile can be seen.
a, b, c, d, e, f: Initially. g, h, i, j, k, l: After treatment. m, n, ñ, o, p: After one year of retention.

37 científica dental. vol 12 (special supplement) 2015.

C. Temporomandibular dysfunction with mandibu- destruction of the crown which makes restorative
lar retroposition treatment difficult; particularly extensive decay and
severe enamel defects (isolated hypoplasia and inci-
It has been suggested that the removal of a lower in-
sor-molar syndrome).
cisor facilitates the anterior reposition of the
mandible in patients with TMJ dysfunction and Angle Therapeutic removal of first molars may also be con-
Class I malocclusions without residual growth. sidered for eruption disorders, whether due to anky-
losis or ectopies of difficult renewal. Extracting the
Table III lists the undesirable effects and contraindi-
first molar with a pathology may be an alternative to
cations of therapeutic extraction of a lower incisor36.
a first premolar. When there is no indication to ex-
2.2 Extraction of the first molars tract premolars, the space left by the removal can be
closed by mesialisation of the second molars and
The functional significance of the first molars means eventually the wisdom teeth. In this case, the final
they are rarely suggested for extraction in the con- occlusal position should be considered beforehand,
ventional treatment of malocclusion. However, it is depending on the molars remaining after extraction.
not uncommon to find first molars affected by severe
pathologies, such that their removal is considered In adult patients, the most common cause of perma-
within an interdisciplinary therapeutic plan. Among nent molar extraction is periodontal disease of the
these pathologies are those that involve significant tooth.

TABLE I: TYPICAL PATTERNS OF 2.3 Extraction of temporary teeth

TOOTH EXTRACTIONS IN Temporary teeth extraction is an important prophy-
ORTHODONTICS: INDICATIONS
lactic weapon in the development of certain maloc-
EXTRACTION PATTERNS INDICATIONS clusions. However, it is a subject of constant debate
- First 4 bicuspids - Angle class I with: and clashes between orthodontists, who indicate the
- Crowding and/or
extractions, and paediatric and general dentists who
- Biprotrusion and/or
- Open bite. have to perform them and do not always understand
- First 2 upper bicuspids - Angle class II. the need for them. Removing temporary teeth can
- First upper bicuspids and second lower - Class II with: be prescribed in a timely and well located manner
- Overjet and/or
- Crowding.
either or within the framework of a programmed
- First 2 lower bicuspid - Angle class III. eruption guide.

Specific indications for removal of temporary teeth

without a predetermined pattern are very common;
TABLE II. REASONS FOR ATYPICAL thus, only a few of the most frequent in orthodontic
ORTHODONTIC EXTRACTIONS AND practice will be outlined.
TEETH EXTRACTED
Firstly, the prevention of permanent teeth impaction
REASONS FOR EXTRACTION TOOTH TO BE EXTRACTED
must be mentioned. Important in this area is the re-
- Correction of the midline. - Bicuspid
- Asymmetric malocclusions search by Ericson and Kurol on prophylaxis of the im-
- Bolton Discrepancy - Lower Incisor paction of palatal maxillary canines in cases of
- Lower crowding in Class III eruptive deviation during the period of mixed denti-
- Agenesis of a lateral incisor - Upper lateral incisor
(contralateral)
tion40-41. These authors showed that the extraction
- Ectopy, impaction - Upper canines of canines, and eventually the first upper molars, in
- Ankylosis children with deviation of the permanent ones pre-
- Intrinsic pathology - Tooth affected
vented their evolution to inclusion in 60-90% of

científica dental. vol 12 (special supplement) 2015. 38

 TABLE III: UNDESIRABLE EFFECTS AND CONTRAINDICATIONS FOR
THERAPEUTIC EXTRACTION OF A LOWER INCISOR
UNDESIRABLE EFFECTS - Excessive overjet and overbite.
- Reopening of extraction space.
- Inadequate posterior occlusion.
- Loss of interincisor papilla with appearance of "black triangles".
- Mesial inclination of the lower canines.
- Excessive lingual inclination of the remaining lower incisors.
- Inconsistency of midlines (inevitable).
CONTRAINDICATIONS - Bolton Discrepancy, upper excess.
- Increased overbite.
- Triangular anatomy of lower incisors, especially with periodontal disease.
- Increased overjet.

cases. This prophylactic extraction procedure of tem- treatment of malocclusion in temporary or mixed
porary canines deserves special consideration in pa- dentition or prevent its full development44.
tients with agenesis of the lateral incisors for its
proven association with canines. However, many authors have pointed out the impor-
tance of extreme prudence and knowledge of the
Another indication that is frequently suggested is the pathophysiology of the eruption when using this
extraction of temporary second molars in cases of im- therapeutic tool. In inexpert hands, significant unde-
paction of the permanent first with infraocclusion. In sirable effects can occur by improperly handling the
these cases, a distal reduction of the second tempo- anchor and maintaining spaces, for example. In short,
rary molar (slicing) can be performed; but if this is not programmes guiding the eruption are far from being
enough, they must be extracted. Usually, the perma- a rigid solution that apply in all cases; but must be
nent molar erupts spontaneously afterwards, but is tailored to each patient's pathology, ending or not in
essential to control the loss of the space required for the removal of the first bicuspids45.
the premolar successor.

Finally, mention must be made of the extraction of

the temporary incisors in the presence of eruptive al- CONCLUSIONS
terations of the permanent successors. The etiology
Dental extractions are a highly useful weapon in the
of their impaction is multiple: traumatic events with
prophylaxis and treatment of numerous malocclu-
the incisor itself or its temporary predecessor; the
sions. However, their use requires great caution and
presence of obstacles such as supernumerary teeth,
a thorough understanding of the pathophysiology of
odontomas or cysts; or jaw malformations, especially
eruption, occlusion and facial aesthetics. The ortho-
a cleft palate. In all these cases, when the temporary
dontist is faced with numerous facial and dental de-
predecessor persists, usually removal is indicated, as-
formities which cannot be managed by the rigid
sociated or not with other orthodontic or surgical
application of treatment plans; and this is particularly
procedures28,42,43.
applicable to tooth extractions. Adult patients often
2.4 Guiding eruption have very complex pathologies which pose many
challenges to the orthodontist, among which are the
A programme of serial extraction of temporary teeth ability to remove or keep teeth and to manage this
or, even better, a guide to eruption may facilitate the within an interdisciplinary approach.

39 científica dental. vol 12 (special supplement) 2015.

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41 científica dental. vol 12 (special supplement) 2015.