Download Extraction in the Mixed Dentition

2/5/2015
A Reasonable
Alternative for
Selected Patients?
Extraction in the
Mixed Dentition ─
1
2
“War of Roses” Tennessee
Governor's Race 1886
I declare that neither I, nor any member of my
family, has a financial arrangement or affiliation
with any corporate organization which offers
financial support or grant monies for this
continuing education presentation, nor do I have a
financial interest in any commercial product(s) or
services I will discuss in this presentation.
The Taylor Brothers
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N. Nash
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2/5/2015
N. Nash
N. Nash
N. Nash
N. Nash
N. Nash Pretreatment
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
Options
70
20
90
83
80
3
4mm
0
90
1.Space Management
2.Expansion – Arch
Development
3.Extraction in the Mixed
Dentition
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But ─ Before Options Are
Considered ─
How Much Space
Is Needed?
How Much Space is Needed?
13
Totals
Maxillary Arch
Space Required
16.5mm
Space Available
8.0mm
Deficit
8.5mm
4mm
4mm
20.0mm
18.5mm
Mandibular Arch
Space Required
46.1mm
Space Available
38.5mm
Deficit
7.6mm
Space Available
Option
16
Maxillary Arch ─ Must
Have 8.5mm
Space
Management
4mm
4mm
17
No Space
to Manage
18
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Space Management
Space Management
Mandibular Arch
Left side ─
Yes
18.5mm
20.0mm
Right side
- 4.6mm
?
Plus
Interproximal
Reduction?
19
Option
Space Needed
Maxillary Arch ─ 8mm
Mandibular Arch ─ 7.6mm
Interproximal
Reduction???
Space
N. Nash
Space
20
Make Space for
the Teeth
21
22
Make Space for the Teeth
Expansion ─ Arch
Development
Does Our Science
Need to be Consulted?
Yes!
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Sinclair and Little (1983)
• Sinclair and Little (1983) Reported on a
Sample of 65 Subjects With Normal
Occlusions For Changes in the Dental
Arch From the Mixed Dentition, to Early
Permanent Dentition, and into Early
Adulthood.
• Arch Length Decreased From the Mixed
Dentition into Early Adulthood While
Incisor Irregularity Increased From 13 to
20 Years of Age.
What Happens
With No
Treatment?
26
25
Richardson (1999)
• Evaluated the Changes in Alignment in the
Untreated Lower Arch at Various
Developmental Stages: 7 to 15 Years, 13 to
18 Years, 18 to 21 Years, and 18 to 50
Years.
• After Evaluation of the Dental Arch at
Various Developmental Stages, Richardson
(1999) Concluded That the Greatest
Increase in Amount of Lower Incisor
Crowding Occurs Between the Ages of 13
and 18 Years of Age (= 2.3 mm).
27
Does Arch Length Inevitably Decrease
From Mixed Dentition to Adult Dentition?
Barrow & White, AJO 1952
Brown, et al, Act. O Scand 1951
Little, et al, AJO 1990
Lundstrom, Dent Pract 1969
Moyers, HandBK of Ortho 1985
Moorees, Harv Univ Press 1959
Nance, AJO 1947
Sinclair, et al, AJO 1983
Sillman, AJO 1964
Yes!
28
When Mandibular Incisors Are Proclined
During Treatment, Do They Tend to
Upright?
What Happens
Nance, AJO 1947
Mills, Brit Ortho Jrn 1966
Litowitz, Angle Ortho July-Oct 1948
Cole, Angle Ortho July-Oct
Hixon, AJO 42:898, 1956
Hixon, Angle Ortho 42:200, 1972
Weinstein, Angle Ortho 33: 1, 1963
Miller, U of Oregon Thesis 1971
Boley, UMKC Thesis 1966
With
Treatment?
29
Yes!
30
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Do Expanded Mandibular Canines
Typically Constrict After the Removal of
Retention?
Bishara, et al, AJO1989
Glenn, et al, AJO 1987
Little, et al, AJO 1981
McCauley, AJO 1944
Riedel, Angle Ortho 1966
Sandusky, Thesis 1983
Shapiro, AJO 1974
Sondhi, et al, AJO 1980
Steadman, Angle Ortho 1961
Strang, Angle Ortho 1949, 1952
Yes!
de la Cruz A, Sampson P, Little RM, Artun J, Shapiro PA.
Long-term Changes In Arch Form After Orthodontic
Treatment And Retention. Am J Orthod Dentofacial Orthop. 1995 May;
107(5):518-30.
• Arch form tended to return toward the
pretreatment shape after retention.
• Greater the treatment change, the greater the
tendency for postretention change.
• However, individual variation was considerable.
• Patient's pretreatment arch form appeared to be
the best guide to future arch form stability.
31
Kahl-Nieke B, Fischbach H, Schwarze CW. Post-retention
Crowding And Incisor Irregularity: A Long-term Follow-up
Evaluation Of Stability And Relapse. Orthod. 1995
Aug;22(3):249-57.
32
El-Mangoury NH. Orthodontic Relapse In Subjects With Varying
Degrees Of Anteroposterior And Vertical Dysplasia. AJO/DO, Vol. 75,
#5, May 1979, pp 548-561.
Over expansion was found to be a
factor in mandibular incisor
relapse.
• In both the- stable and the relapse groups, the
mandibular intercanine width decreased
postretention. This decrease was associated more
with the relapse group than with the stable group.
• The mandibular intercanine width tended to relapse
toward its original pretreatment value. This suggests
that, at the end of active treatment, the mandibular
intercanine width should be maintained as originally
presented.
• There was no significant interaction between
orthodontic relapse (or stability) and whether or not
extraction was included as a part of the
mechanotherapy.
33
The Washington Studies Should
Not Be Interpreted to Mean That
The Position of the Teeth
Does Not Matter
34
Little RM, Riedel RA, Enqst ED. Serial extraction of first premolarspostretention evaluation of stability and relapse. Angle Orthod. 1990
Winter;60(4):255-62.
• Twenty-two of the 30 cases (73%) demonstrated clinically
unsatisfactory mandibular anterior alignment postretention.
• Intercanine width and arch length decreased in 29 of the 30
cases by the postretention stage.
Artun J, Garol JD, Little RM. Long-term stability of mandibular incisors
following successful treatment of Class II, Division 1, malocclusions.
Angle Orthod. 1996;66(3):229-38.
• At post-retention, 9.0% had irregularity index values of 6.5
mm or more and 47.4% had values equal to 3.5 mm or less.
• Treatment increase of intercanine width and post-retention
decrease of intercanine width and arch length were
associated with relapse.
35
36
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There Are No Studies of
Patients Treated With
Expansion Who Have Been
Recalled Twenty Five Years
After Treatment
Treatment Plan With
Strang, Nance, Tweed,
Merrifield, Mangoury,
Blake & Bibby, & Boley!
So — What Should We
Do?
37
38
Strang, R.H.W. “The Fallacy Of Denture
Expansion As A Treatment Procedure.”
The Angle Orthodontist, 1949: 49: 12 17.
Tweed, CH. “Indication for the
Extraction of Teeth in Orthodontic
Procedures,” AM J of Ortho Oral Surg
30:405, 1944.
Nance, H. “The Limitations of Orthodontic
Treatment”, Am J of Ortho & Oral Surg
33:253-301, 1947.
Tweed, CH. “A Philosophy of
Orthodontic Treatment”, Am J of Ortho
& Oral Surg 31:74, 1945.
39
Merrifield, LL. “The Dimension
of the Denture: Back to the
Basics,” AJO/DO Vol106:535,
1994.
40
Boley JC, Mark JA, Sachdeva RC, Buschang PH.
"Long-term stability of Class I premolar extraction
treatment." Am J Orthod Dentofacial Orthop. 2003
Sep;124(3):277-87.
Paquette DE, Beattie JR, Johnston LE Jr. "A longterm comparison of nonextraction and premolar
extraction edgewise therapy in "borderline" Class II
patients." Am J Orthod Dentofacial Orthop. 1992
Jul;102(1):1-14.
Merrifield, LL. “Differential
Diagnosis,” Seminars in
Orthodontics #2, 241, 1996.
41
42
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The Face ─
It Can!
Does Expansion
Compromise Facial
Esthetics?
Many Times It
Does
43
Expansion Can Harm
Facial Esthetics
44
Is There An
ANTERIOR LIMIT
OF THE DENTITION?
45
46
47
48
Merrifield’s Z Angle
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Tweed, CH. “The Frankfort
Mandibular Incisor Angle (FMIA) In
Orthodontic Diagnosis, Treatment
Planning and Prognosis”, Am J of
Ortho & Oral Surg 24:121, 1954.
STEINER
Burrow, SJ. “Smile Esthetics After
Orthodontic Treatment With and
Without Extraction of Four First
Premolars,” Seminars in Orthod,
Vol 18, #3, Sept 2012 pp 201-209.
49
50
Expansion – Arch Development
Maxillary Arch ─ Must have 8.5mm
Now ─
4mm
4mm
Some Specific
Questions
51
52
─ Yes ─
Can We
Expand the
Maxillary Arch?
But Should We?
53
54
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1mm of Lateral Expansion
Adkins MD, Nanda RS,
Currier GF. Arch Perimeter
Changes on Rapid Palatal
Expansion. Am J Orthod
Dentofacial Orthop. March
1990;97(3);194-199.
Yields .66 mm of Arch
Perimeter Gain
Expansion Required ≈ 12mm
55
Schiffman PH, Tuncay OC. Maxillary
expansion: a meta analysis. Clin Ortho Res,
2001 May;4(2); 86-96.
The mean expansion after adjustment according to
the principles of meta analysis was 6.00 mm with a
standard deviation of 1.29 mm. Of the 6-mm average,
4.89 mm was retained while wearing retainers…
Finally, in the long-term post-retention study period
only 2.4 mm of the residual expansion was reported
to have remained. This 2.4 mm of expansion
remaining after more than a year or more of postretention period was no greater than what has been
documented as normal growth.
57
If We Expand the
Maxillary Dentition in the
Absence of Crossbite ─
We MUST EXPAND
the Mandibular
Dentition
59
56
Gianelly AA. Rapid Palatal
Expansion in the Absence of
Crossbites: Added Value?
Am J Orthod Dentofacial
Orthop. October 2003;
124(4);362-365.
58
Gianelly – “One conclusion is
that the use of the maxillary
arch as the template for the
mandibular arch might
jeopardize the stability of the
mandibular arch by expanding
it in areas that are known to be
unstable.”
60
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Burke SP, Silveira AM,
Goldsmith LJ, Yancey JM, Van
Stewart A, Scarfe WC. “A
Meta-Analysis of Mandibular
Intercanine Width in Treatment
and Postretention", Angle
Ortho. February 1998; 68:5360.
Is It Prudent to
Expand the
Mandibular
Dentition?
61
Burke et al Performed a
Meta-Analysis of 26 Articles –
Evaluated 1233 Patients
Conclusion: Most Prudent
Course Is to Maintain the
Original Intercanine Dimension
62
Conclusion – Lateral Maxillary
Expansion is Probably Not a
Good Solution for Our Patient
4mm
4mm
63
Lateral Mandibular
Expansion is Not a
Prudent Option
20.0mm
64
What About
Moving the Teeth
Distally?
18.5mm
Not Laterally?
65
66
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THE POSTERIOR LIMIT OF
THE DENTITION
Is There a
Posterior Limit of
the Dentition?
Yes!!
67
68
This Patient is
17 years old.
A Modern
“Widget”
The second
molars are
impacted due to
distalization
mechanics.
69
We Can Easily Push the
Maxillary Teeth Distally
70
AJO/DO Vol 146, No 2
But What About
the Mandibular
Teeth?
71
72
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What About
Maintaining the
Position of the
Mandibular
Posterior Teeth?
73
74
14 Months into Treatment
K. Cox
K. Cox
75
76
AJO/DO Vol 141, No 2
K. Cox
77
78
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300 Patients ─ Four Groups
– Schwarz
– Lingual holding Arch
– Combination of Schwarz
& Holding Arch
– Control
Rebecca Lash Rubin, Tiziano Baccetti, and
James A. McNamara, Jr
79
Findings / Conclusions
Orthodontic Appliances
Intended to Maintain Arch
Perimeter in the Mixed
Dentition Increase the
Probability of Eruption
Disturbances of the
Mandibular Second Molars.
80
Findings / Conclusions
“All 3 Treatment Groups
Had a Higher Incidence
of Mandibular Second
Molar Eruption Difficulty
When Compared with the
Controls.”
81
The Bottom Line
on Arch
Development
83
82
“Most Often the Arch Length Gain
Occurs by Lower Incisor
Proclination and/or An Increase in
Intercanine Width, Both Being
NOTORIOUSLY Unstable.”
David Kennedy
Early Treatment Options
PCSO Bulletin – Summer 2010
84
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85
Bowman SJ. “Pulsus a
Mortuus Equus”
86
Lysle E. Johnston Jr
(Beating a Dead Horse)
MORE Bone or
LESS Teeth!
Seminars in Orthodontics, Vol 20,
#1, 2014, pp 36-45.
Arguments About Age – Appropriate
Arch Length Alternatives.
That is the Choice!
87
Peck, Sheldon. “The Current Fashion of Nonextraction Dental
Arch Expansion in Orthodontics: A Critique” Seminars in
Orthodontics, Vol 18, #2, June 2012, pp 126-127.
Today, conscientious orthodontists are
being challenged by commercially
marketed appliance systems that promise
easy solutions and are based on
nonextraction dental arch expansion. This
is a throwback to orthodontic methods
advocated a century ago, long before the
evidence-based era of orthodontics,
radiography, and periodontology.
89
88
Arch Development
Little RM, Riedel RA, Stein A.
Mandibular Arch Length Increase During
Mixed Dentition: Postretention
Evaluation of Stability and Relapse. Am
J Ortho Dentofacial Orthop. May
1990:97 (5):393-404.
It is a FAILURE 87%
of the Time
90
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“…this strategy shows
greater relapse than other
samples we have
collected.”
Am J Orthod Dentofacial Orthop
2006; 130:202-13
Little RM, Riedel RA, Stein A. Mandibular arch length
increase during the mixed dentition: postretention evaluation
of stability and relapse. Am J Orthod Dentofacial Orthop.
91
1990; 97(5);393-404.
92
93
Mandibular Arch
Perimeter
Decreased in Both
Treated Samples
95
94
What is the Best
Choice for Natalie?
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Options
Option
1.Space Management
2.Expansion – Arch
Development
3.Extraction in the Mixed
Dentition
Extraction in the
Mixed Dentition
97
Age 6
98
..."It is better to have one or two
teeth less in each jaw, provided it
can be compensated by a suitable
arrangement, than to have the
entire set of teeth poorly arranged
and ill at ease…”
Bunon R. Essay sur las maladies des dents. Conference. In:
Paris; 1743.
99
“By sacrificing the (deciduous)
canine teeth to the incisors and
the small molars (premolars) to the
(permanent) canines it will be
possible to leave free space to
make an attractive arrangement."
Bunon R. Essay sur las maladies des dents. Conference. In:
Paris; 1743.
101
100
In 1896, J.F. Colyer advocated extractions “to
gain room for the crowns and roots, to
decrease mechanical treatment and in many
cases to abolish it as well as to relieve the
pressure on the teeth and prevent caries, to
improve the bite, and finally to have the teeth
naturally assuming a better position”.
Colyer J. Discussion on the early treatment of crowded
mouths. Odont Soc Trans. 1896;28(2):215–33.
102
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Kjellgren B. Serial Extraction as a
Corrective Procedure in Dental
Orthopedic Therapy, Eur. Orthod.
Soc. Trans p134, 1947–1948.
The phrase Serial
Extraction has resulted in
the poorly planned
removal of teeth by people
who do not have the
necessary knowledge.
Special Knowledge is
Required
Jack Dale
103
Hotz R. Guidance of eruption
versus serial extraction, Am J
Orthod 58:1, 1970.
Hotz’s Guidance of Eruption
implies that knowledge of
growth and development is
necessary to direct the teeth
as they erupt.
104
“Guidance of Occlusion –
an even better term
because occlusion is the
final destination of a tooth
that is erupting.”
─ Jack Dale
105
106
107
108
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This chapter is THE State of
the Art work on extraction of
teeth in the mixed dentition.
• Fabulous Illustrations
• Impeccably Referenced
• Meticulous Explanations
This chapter is a
MUST reference for
every clinical
orthodontist.
110
109
Graber TM. Serial extraction: a continuous
diagnostic and decisional process. Am J Orthod.
1971;60:541-75.
Heath J. The interception of
malocclusion by planned serial
extraction. New Zealand J.
1953;49:77-88.
Dewel BF. Serial extraction; its
limitations and contraindications.
Ariz Dent J. 1968;14(6):14-30.
112
111
Dewel BF. Prerequisites in serial
extraction. Am J Orthod. 1969;55:533-9.
Dewel BF. Editorial. A question of
terminology: serial extraction or
guidance of eruption. Am J Orthod.
1970;58:78-9.
Dewel BF. Precautions in serial
extraction. Am J Orthod. 1971;60:615-8.
113
Lloyd ZB. Serial extraction as a
treatment procedure. Am J Orthod.
1956;42:728-39.
Tweed CH. Treatment planning and
therapy in the mixed dentition. Am J
Orthod. 1963;49:881-906.
Jacobs J. Cephalometric and clinical
evaluation of class I discrepancy cases
treated by serial extraction. Am J Orthod.
1965;51:401-11.
114
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Dale JG, Brandt S. Dr. Jack G. Dale on
serial extraction. J Clin Orthod.
1976;10(1):44-60.
Dale JG, Brandt S. Dr. Jack G. Dale on
serial extraction. 2. J Clin Orthod.
1976;10(2):116-36.
Dale JG, Brandt S. Dr. Jack G. Dale on
serial extraction. 3. J Clin Orthod.
1976;10(3):196-217.
Proffit WR. The timing of
early treatment: an
overview. AM J Orthod
Dentofac Orthop. 2006;
129:47-49.
115
116
A Careful Analysis
Prior to ANY
Extraction Decision
• Face
• Skeletal Pattern
Complete Records
• Teeth
Treatment Plan
117
The Face
Mixed dentition
extraction procedures
seem to work best when
the face has balance or is
at best, mildly protruded.
119
118
The Face
Mixed dentition
extractions are generally
contraindicated in a
convex or concave face.
120
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The Face
The Skeletal Pattern
Vertical
Dimension
should be within
NORMAL Limits
121
122
The Skeletal Pattern
Mixed dentition
extractions are generally
contraindicated in patients
with hyperdivergent or
hypodivergent skeletal
patterns.
123
124
The Skeletal Pattern
The anteroposterior relationship
of the maxilla to the mandible
should be “normal.” If the
mandible is either retrognathic
or prognathic, mixed dentition
extractions are generally not
indicated.
125
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What About
Mixed Dentition
Extraction in the
Class II Dental
Relationship?
Proceed with
Caution!
127
128
Be Prepared to
1) Correct the Class II
Molar Relationship with
Mandibular Extraction
2) Treat to a Class I
Canine / Class II Molar
HB Byers
HB Byers
129
130
HB Byers
131
132
22
HB Byers
2/5/2015
HB Byers
133
134
Dugoni SA. Comprehensive mixed dentition
treatment. Am J Orthod Dentofac Orthop. 1998;113,
p75–84.
Dugoni SA, Aubert M, Baumrind S. Differential
diagnosis and treatment planning for early mixed
dentition malocclusions. Am J Orthod Dentofac
Orthop. 2006; 129, Issue 4, S80–S81.
HB Byers
135
The Dentition
The Clinician MUST ascertain
the space required and the
space available.
And  Other Factors?
137
136
Ringenberg Q. Serial extraction: Stop, look, and be certain.
Am J Orthod. 1964;50:327–36.
Proffit WR. The timing of early treatment: an overview. Am J
Orthod Dentofac Orthop. 2006;129:47–49.
Arch Length/Tooth Size Deficiency
• How much crowding would indicate that
extractions of permanent teeth may be
indicated?
• 7mm or more of crowding was an
indication (Ringenberg)
• 10 mm or more of crowding (Proffitt)
138
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The Dentition
There are several methods that
can be used to predict the
space needed and the space
required.
Whatever the method of choice,
USE IT!
Hixon EH, Oldfather RE.
Estimation of the sizes of
unerupted cuspid and bicuspid
teeth, Angle Ortho 28:236, 1958.
Huckaba GW. Arch size analysis
and tooth size prediction. Dent
Clin North Am 431, 1964.
139
Gardner RA. “A Comparison of
Four Methods of Predicting
Arch Length” Am J Orthod,
1979, 75(4) 387-398.
“Tanaka and Johnston Analysis
seems to be the one most
frequently used since it is a pure
calculation.”
141
140
The “Dale” Method
• Space Available vs Space Required
• Curve of Spee Correction
• Evaluation of Protrusion
(Its Correction Requires Space)
• Posterior Dentition Area Evaluation
Jack Dale, Chapter 11
142
Therefore, a THOROUGH Study of:
Age 9
The Face
The Skeletal Pattern
The Dentition
MUST Be Done in Order to
Formulate a Mixed Dentition
Extraction Treatment Plan.
143
144
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Four First Premolars Were Removed
During the Mixed Dentition.
145
146
Age 11
147
What is the Best
Choice for Natalie?
Four First
Premolars and
Mandibular
Deciduous Teeth
Were Removed
149
N. Nash
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N. Nash
N. Nash
N. Nash
N. Nash
N. Nash
N. Nash
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N. Nash
N. Nash
N. Nash Pretreatment
N. Nash Progress
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
70
20
90
83
80
3
4mm
0
90
70
20
90
83
80
3
4mm
0
90
N. Nash
Pretreatment
Progress
160
N. Nash
N. Nash
162
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N. Nash
N. Nash
163
N. Nash
164
N. Nash
165
N. Nash
166
N. Nash
167
168
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N. Nash
N. Nash
N. Nash Pretreatment
N. Nash Posttreatment
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
70
20
90
83
80
3
4mm
0
90
N. Nash
69
19
92
83
80
3
0mm
0
90
Pretreatment
Progress
Posttreatment
N. Nash
172
N. Nash
173
174
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Is Mixed Dentition
Extraction Expedient
For the Majority of
Crowded Class I
Dentitions?
N. Nash
M. Denman
NO!!!!
176
M. Denman
177
178
M. Denman Pretreatment
M. Denman
179
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
UL
TC
PFH
AFH
INDEX
77
21
82
78
78
0
-4mm
10
79
16mm
14mm
43mm
60mm
.70
180
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M. Denman
181
M. Denman
M. Denman
182
M. Denman
183
M. Denman
185
184
M. Denman Pretreatment
M. Denman Recall
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
UL
TC
PFH
AFH
INDEX
FMIA
FMA
IMPA
SNA
SNB
ANB
AO-BO
OCC
Z
UL
TC
PFH
AFH
INDEX
77
21
82
78
78
0
-4mm
10
79
16mm
14mm
43mm
60mm
.70
77
21
82
78
79
-1
-4mm
8
80
16mm
14mm
47mm
62mm
.75
186
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M. Denman
Pretreatment
Posttreatment
Recall
187
M. Denman
188
M. Denman
189
190
Extraction of Teeth in the
Mixed Dentition ─
A Reasonable Option for
Selected Patients?
192
191
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Two Key Words
In My Caveman Practice ─
Less Than 10%!! of the
Patients Between the Ages
of 8 and 12 Have Mixed
Dentition Extractions
•Reasonable
•Selected
193
194
If It Is
Reasonable ─ And If
the Patient Has the
Criteria
IT IS A GREAT PATIENT
SERVICE!
195
Age 15
196
Fifty-Eight Years After
Mixed Dentition
Extraction
No Other Treatment
197
198
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199
200
Thank You!
Age 68
201
34