Extraction teeth for gaining space in

orthodonticsSupervisor Prof Maher Fouda

Prepared by Ameen mohammedMansoura University -Faculty of Dentistry

Department of Orthodontics Egypt

IntroductionThe need for extraction in orthodonticsChoice of teeth for extractionMaxillary Incisors indication contraindication case report mandibular incisors Indication contraindication case report + vidCanines indication contraindication case report First premolars indication contraindication case report +vidSecond premolars indication contraindication case report +vidMaxillary First molar indication contraindication case report Maxillary second molar indication contraindication case report mandibular First molar indication contraindication case report mandibular second molar indication contraindication case report +vidmandibular third molar indication contraindication case report

Extraction teeth for gaining space in orthodonticsPainless removal of teeth from its socket is termed

as extraction Extraction in orthodontics is a therapeutic method to

gain space for relieving crowdingExtractions in orthodontics remains a relatively

controversial area It is not possible to treat all malocclusions without taking out any teeth

Extractions in orthodontics may be carried out as an -interceptive procedure during the mixed dentition as serial extraction

And as therapeutic extractions carried out as treatment procedure for gaining space

THE NEED FOR EXTRACTIONExtraction of teeth may be required in the following circumstancesArch Length-Tooth Material Discrepancy Correction of Sagittal Inter arch Relationship

Extraction for the Relief of crowding must be observance

A-Condition of the teethB-Position of the crowdingC-Position of the teeth

Arch Length-Tooth Material DiscrepancyIdeally the arch length and tooth material should be in harmony with each other

If the dentition is too large to fit in the dental arch without irregularity it may be necessary to reduce the dentition size by the extraction of teeth It is not normally acceptable to increase the dental arch size because the increased dental arch dimension would not be tolerated by the oral musculature

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

IntroductionThe need for extraction in orthodonticsChoice of teeth for extractionMaxillary Incisors indication contraindication case report mandibular incisors Indication contraindication case report + vidCanines indication contraindication case report First premolars indication contraindication case report +vidSecond premolars indication contraindication case report +vidMaxillary First molar indication contraindication case report Maxillary second molar indication contraindication case report mandibular First molar indication contraindication case report mandibular second molar indication contraindication case report +vidmandibular third molar indication contraindication case report

Extraction teeth for gaining space in orthodonticsPainless removal of teeth from its socket is termed

as extraction Extraction in orthodontics is a therapeutic method to

gain space for relieving crowdingExtractions in orthodontics remains a relatively

controversial area It is not possible to treat all malocclusions without taking out any teeth

Extractions in orthodontics may be carried out as an -interceptive procedure during the mixed dentition as serial extraction

And as therapeutic extractions carried out as treatment procedure for gaining space

THE NEED FOR EXTRACTIONExtraction of teeth may be required in the following circumstancesArch Length-Tooth Material Discrepancy Correction of Sagittal Inter arch Relationship

Extraction for the Relief of crowding must be observance

A-Condition of the teethB-Position of the crowdingC-Position of the teeth

Arch Length-Tooth Material DiscrepancyIdeally the arch length and tooth material should be in harmony with each other

If the dentition is too large to fit in the dental arch without irregularity it may be necessary to reduce the dentition size by the extraction of teeth It is not normally acceptable to increase the dental arch size because the increased dental arch dimension would not be tolerated by the oral musculature

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction teeth for gaining space in orthodonticsPainless removal of teeth from its socket is termed

as extraction Extraction in orthodontics is a therapeutic method to

gain space for relieving crowdingExtractions in orthodontics remains a relatively

controversial area It is not possible to treat all malocclusions without taking out any teeth

Extractions in orthodontics may be carried out as an -interceptive procedure during the mixed dentition as serial extraction

And as therapeutic extractions carried out as treatment procedure for gaining space

THE NEED FOR EXTRACTIONExtraction of teeth may be required in the following circumstancesArch Length-Tooth Material Discrepancy Correction of Sagittal Inter arch Relationship

Extraction for the Relief of crowding must be observance

A-Condition of the teethB-Position of the crowdingC-Position of the teeth

Arch Length-Tooth Material DiscrepancyIdeally the arch length and tooth material should be in harmony with each other

If the dentition is too large to fit in the dental arch without irregularity it may be necessary to reduce the dentition size by the extraction of teeth It is not normally acceptable to increase the dental arch size because the increased dental arch dimension would not be tolerated by the oral musculature

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extractions in orthodontics may be carried out as an -interceptive procedure during the mixed dentition as serial extraction

And as therapeutic extractions carried out as treatment procedure for gaining space

THE NEED FOR EXTRACTIONExtraction of teeth may be required in the following circumstancesArch Length-Tooth Material Discrepancy Correction of Sagittal Inter arch Relationship

Extraction for the Relief of crowding must be observance

A-Condition of the teethB-Position of the crowdingC-Position of the teeth

Arch Length-Tooth Material DiscrepancyIdeally the arch length and tooth material should be in harmony with each other

If the dentition is too large to fit in the dental arch without irregularity it may be necessary to reduce the dentition size by the extraction of teeth It is not normally acceptable to increase the dental arch size because the increased dental arch dimension would not be tolerated by the oral musculature

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

THE NEED FOR EXTRACTIONExtraction of teeth may be required in the following circumstancesArch Length-Tooth Material Discrepancy Correction of Sagittal Inter arch Relationship

Extraction for the Relief of crowding must be observance

A-Condition of the teethB-Position of the crowdingC-Position of the teeth

Arch Length-Tooth Material DiscrepancyIdeally the arch length and tooth material should be in harmony with each other

If the dentition is too large to fit in the dental arch without irregularity it may be necessary to reduce the dentition size by the extraction of teeth It is not normally acceptable to increase the dental arch size because the increased dental arch dimension would not be tolerated by the oral musculature

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Arch Length-Tooth Material DiscrepancyIdeally the arch length and tooth material should be in harmony with each other

If the dentition is too large to fit in the dental arch without irregularity it may be necessary to reduce the dentition size by the extraction of teeth It is not normally acceptable to increase the dental arch size because the increased dental arch dimension would not be tolerated by the oral musculature

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Arch Length-Tooth Material Discrepancy

Ideal occlusionAngle believed that all 32 teeth could be accommodated in the jaws in an ideal occlusion with the first molars in a Class I occlusion with the mesiobuccal cusp of the upper first molar occluding in the buccal groove of the lower first molar

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Correction of Sagittal Interarch Relationship

Abnormal sagittal malrelationship such as Class II Ill malocclusion may require extraction to achieve a normal interarch relationship

Class II Class III

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Correction of Sagittal Interarch RelationshipIn a Class I malocclusionit is preferable to extract in both the arches because it is not advisable to discourage the development of only one arch more than the otherIn most Class II cases with abnormalof the lower teeth and where a point is upper proclination normal alignment abnormally forward relative to the B pointClass III cases are usually treated by extracting teeth only in the lower arch

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction for the Relief of CrowdingExtraction for the relief of crowding will be governed byCondition of the teethGrossly carious teeth root canal treated teeth and teeth with large restorations are preferred for extraction over healthy teethPosition of the crowding Crowding in one part of the arch is more readily corrected if extractions are done in that part rather than a remote area of the arch However incisor crowding is usually relieved by premolar extraction as it gives a more pleasing appearance and occlusal balance than with incisor extractionThe first premolar positioned in the center of each quadrant is usually near the area of crowding whether in the anterior or buccal segment

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

CHOICE OF TEETH FOR EXTRACTION

Choice of teeth to be extracted depends un local conditions which includeDirection and amount of jaw growthDiscrepancy between size of dental arches and basal

archesState of soundness position and eruption of teeth

facial profileDegree of dentoalveolar prognathismAge of patientState of dentition as a whole

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

INCISORSMaxillary IncisorsThe maxillary central incisors are rarely extracted as a part of orthodontic therapyIndications for maxillary incisor extractionUnfavorably impacted maxillary incisorsBuccally or Lingually blocked out lateral incisor with good contact

between central incisor and caninesIf a lateral incisor is crowded in linguo-occlusion with its apex

palatally displaced and if the canine is erupting in a forward position and is upright or distally inclined lateral incisor extraction is indicated

Grossly carious incisor that cannot be restoredTraumairreparable damage to incisors by fracture

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case report central incisorsExtraction of upper central incisors is not common in

orthodontics However malformed central incisors with poor prognosis could be candidates for extraction

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

pretreatment

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment plane Based on clinical and radiographic findings together with poor prognosis of upper central incisors and the appropriate size of lateral incisors with long roots extraction of the upper central incisors plus substitution of the lateral incisors was determined as a suitable treatment

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment plane Once the maxillary lateral incisors had been situated in the central incisor and the maxillary canines in the lateral incisor positions rectangular stainless steel arch wires were ligated in place to correct the torque in both arches and uprighting of the incisors roots The active orthodontic treatment was completed in 16 visits over the course of 19 months At the completion of orthodontic treatment the smile was consonant and the palatally lateral incisors were corrected Further aims of treatment including preservation of class I molar relationships and creation of normal overjet and overbite were also achieved (Figures 4 and 5) By the completion of orthodontic treatment brackets were removed and the patient was referred for prosthodontic alteration of the shape of teeth The maxillary lateral incisors were built up with Z100-3M resin composite to resemble central incisors Z100-3M Unique single filler is 100 zirconiasilica which allows more particles per gram of paste resulting in excellent strength and wear resistance

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Before

After

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

After

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

BeforeAfter

The cusps of canines were grinded The distal and labial surfaces were flattened and reshaped to mimic lateral incisors and also meet the patientrsquos esthetic requirements

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Indications lower incisor extractionAngle Class I malocclusion with severe anteriortooth size discrepancy (greater than 45 mmlower anterior crowding with lack of space for

approximately one mandibular incisor Dental Class I malocclusions with anterior cross bite due to

crowding and protrusion of the lower incisorsMalocclusions that tend towards a Class III malocclusionModerate Class III malocclusions with anterior cross bite or

incisors with edge-to-edge relationship showing a tendency towards anterior open bite

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Video lower extraction

>

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Indications lower incisor extractionClass II Division 1 skeletal and dental malocclusions with maxillary protrusion and

crowding or protrusion of the lower incisorsCases in which one wishes to avoid increasing intercanine width in certain

malocclusionsAs a non-surgical alternative in Class III treatments Extraction of lower incisors may be appropriate When one incisor is completely excluded from the arch and there are satisfactory

approximal contacts between other incisors

Poor prognosis as in case of trauma caries bone loss etc Severely malpositioned incisor Lower canines are severely inclined distally and lower incisors are fanned-it is very

difficult to correct this condition by extractions further back

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

contraindicationsAll cases requiring extractions in both arches with severe

overbite and horizontal growth pattern bimaxillary crowding no tooth size discrepancy in the anterior teeth

Deep bite cases with horizontal growth patternAll cases which require upper first premolarextraction while canines arc in a Class I relationship Bimaxillary crowding cases with no tooth sizediscrepancy in the incisor areaCases having anterior discrepancy due to eithersma11 lower incisors or large upper incisors

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case ReportA female patient 16 years old reported with a chief complaint of crowding in lower anterior teeth and forwardly placed upper anterior teeth She had a mild convex pleasing facial profile with competent lips

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

intra-oral clinical examination showed severe crowding with mandibular anteriors and mild crowding with maxillary anteriors and angles Class I molar relation bilaterally Due to lower anterior crowding mandibular left canine was displaced buccally [Figure 2] Model analysis showed Boltons ratio mandibular anterior and overall excess of 56 mm and 14 mm respectively

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The main objective of treatment plan was aimed at relieving lower and upper anterior crowding without much disturbing her facial profile Extraction of mandibular left lateral incisor to facilitate proper aligning of lower left canine was planned which would gain space enough to relieve lower anterior crowding

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The orthodontic treatment was started using 0022 slot brackets 0014 inch NiTi preformed arch wire was used as initial wire as to exert very light forces Alignment and levelling was achieved with subsequent wire sequence (Table 1) After levelling using 0019 x 0025 SS arch wire space closure was started with very light forces using tie backsExtraction of one incisor in cases of moderate to severe crowding may even satisfy the requirement of maintaining the arch form and width without expansion of the inter-canine width

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post treatment

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

ConclusionSelecting the best treatment option is often difficult and not all factors can be achieved but a proper case selection and proper decision on which tooth to extract can prove extraction of mandibular incisor a therapeutic extraction option in severe lower anterior crowded cases A systematic treatment approach with simple mechanics and torque control can aid in achieving a stable occlusion that is esthetic and in functional harmony

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

CANINESThe permanent canines are important teeth and are not frequently extracted as a part of orthodontic treatment

Their extraction causes flattening of the face altered facial balance and change in facial expression

When the lower canine is crowded it is sometimes tempting to extract this tooth

However this is avoided because the approximal contact between the lateral incisor and first premolars rarely satisfactory

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

IndicationsMandibular canine may be extracted when it is likely to be very

difficult to align eg when it is excluded from the arch and the apex is severely malpositioned or when it is unfavorably impacted

Maxillary canines develop far away from their final location and have a long path of eruption from their development site to their final position in the oral cavity Therefore they are not uncommonly impacted or ectopic and their alignment is difficult even impossible Extraction may be required in such cases

When maxillary canine is completely excluded from the arch and approximal contact between lateral incisor and first premolar is good extraction of the canine may be considered

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

37-year-old female patient with Class II malocclusion and severe maxillary crowding including palatally displaced upper left lateral incisor and buccally displaced upper left canine (which was completely blocked out of the arch) The upperleft canine showed severe gingival recession and bone loss The upper and lower midlines were shifted to the left by 4mm and 2mm respectively

Case report (1) canine

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

After extraction of both upper canines a passive self-ligating appliance (Damon 3) was bonded in the upper arch from second molar to second molar and an 014 superelastic nickel titanium archwire was placed for initial alignment and correction of the lateral incisor crossbite (Fig 2A)

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Two months later the mandibular arch was bonded from second premolar to second premolar After initial lower alignment an 017 times 025 superelastic nickel titanium wire was placed in the upper arch and an 018 superelastic nickel titanium wire in the lower and Class III elastics were prescribed to improve the overjet (Fig 2B)

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Upper 019 times 025 stainless steel posted and lower 018 stainless steel archwires were placed for finishing with bilateral maxillary tiebacks and interarch elastics used to resolve the remaining lateral open bite (Fig 2C

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

After 12 months of treatment the patient had a bilateral Class II molar relationship with the upper first premolars in the canine positions (Fig 3) The treatment achieved the objectives of crossbite correction and improvement of the patientrsquos smile and facial esthetics

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case report (2) canineThis 1 3 -year-old female presented to my office with the chief

complaint of crooked teeth (Fig 1 ) Her health history was unremarkable

Analysis of the case showed a Class I dental patternmoderate maxillary and mandibular crowding ectopic maxillary canines which were erupting into the mouth from the buccal side and a retained primary canine tooth The panoramic radiograph ( Fig 2 ) shows a transmigrated

mandibular canine with its incisal tip resting at the apex of left lateral in the mandibular symphysis

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Pretreatment photo

Figure 1

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Figure 2

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment option Remove the severely impacted tooth and retained primary

canine Substitute for the missing canine with the first premolarAfter the five treatment options were presented the decision was made to remove the transmigrated canine and to substitute for the loss of the canines with lower first premolars

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

With a plan for substitution after removing the impacted canine and retained primary this case can now be seen as a straight forward Class II subdivision case The PowerScope Class II Corrector (Fig 3) was planned to provide the force to the lower anterior for protracting the right premolars and molars into the substituted position This is a wire to wire attached Class II cor-rector When fully activated it will consistently provide 260g of force for the protraction of the right buccal segment

The Power Scope Class II Corrector

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The Power-Scope has several advantages over Class II elastics for this situation The compressed NiTi spring will provide a predominantly horizontal and only slightly intrusive push-type force mesial to the maxillary molar and distal to the lower canine position

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post treatment photo

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

FIRST PREMOLARSlt is the tooth most commonly extracted as part of orthodontic therapy especially for the relief of crowding becausebull It is positioned near the center of each quadrant of the arch and is therefore near the site of crowding ie the space gained by their extraction can be utilized for correction both in the anterior and posterior regionbull First premolar extraction is the least likely to upset molar occlusion and is the best alternative to maintain vertical dimensionbull The contact between the canine and second premolar is satisfactorybull First premolar extraction leaves behind a posterior segment that offers adequate anchorage for retraction of the 6 anterior teeth

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction first premolars

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Indications1 Tooth of choice for extraction to relieve moderate to severe anterior crowding in both the arches In lower arch crowding where canines are mesially inclined spontaneous improvement in incisor alignment will follow2 Correction of moderate to severe anterior proclinationas in Class II div 1 or Class I bimaxillary protrusion3 In high anchorage cases first premolar takes precedence over second premolar as the teeth to be extracted4 As a part of serial extraction

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

>

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Timing of ExtractionThe first premolars should not be extracted until all premolars

permanent incisors and canines have erupted sufficiently for brackets to be placed on them

The only exception to this rule is when second premolars cannot erupt because they are impacted

The four first premolars should not be extracted more than three weeks before starting active treatment to avoid mesial migration of posterior teeth and therefore leaving insufficient space for retraction

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case reports A 28-year-old male presented with a severe arch-length

discrepancy that had produced severe upper and lower crowding and labially blocked-out canines

He had a Class I molar relationship with the upper and lower left first molars in crossbite Cephalometric analysis showed a Class I straight skeletal profile and normal incisor relationships

A diagnostic cast setup was performed with the four first premolars removed to evaluate the projected alignment of the treated case assuming that the teeth distal to the extraction sites would not move forward

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Pretreatment photo

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treteatment planeThe computer-generated Clin Check setup showing the type and placement of attachments was reviewed modified and accepted (3) Because the canines were mesially angulated the Clin Check technician was instructed to maintain their root angles throughout the retraction phase and not to upright the virtual images as the extraction spaces were closed The case required 50 upper and 49 lower aligners interproximal reduction was not indicated until the middle and later stages (21 and 48)

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Figure 3

Figure 4

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post treatment photo

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

SECOND PREMOLARSIndications for Extraction1 When second premolar is completely excluded from the arch following forwards drift of first molar after early loss of deciduous second molar2 Second premolar extraction is preferred in mild anterior crowding cases as space closure and vertical control is easier after anterior alignment The presence of first premolar anterior to extraction site strengthens the anterior anchorage thereby facilitating closure from behind3 Second premolar extraction is preferred when one wishes to maintain soft tissue profile and esthetics4 Unfavorably impacted second premolars5 Grossly carious or periodontally compromised second premolar 6 In open bite cases second premolar is preferred for extraction as it encourages deepening of the bite

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case reportsThis case report describes the management of 18-year

old female patient with moderate crowding which was treated with second bicuspid extraction At the end of treatment patient had pleasing profile good intercuspation ideal overjet and overbite

The patient had a mild convex profile and symmetric face

chief complaint of unesthetic appearance of her smile

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Pretreatment extra oral and intraoral photo

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

PretreatmentIntra orally the patient had a Super Class I molar relationship

and Class I canine on both sides with an overjet of 3 mm and an overbite of 2 mm with mild anterior crowding and proclination Her lower right canine and upper right lateral incisor were in cross bite

Cephalometric analysis indicated a skeletal Class I relationship with average growth pattern The maxillary and mandibular incisors were mildly proclined with the normal nasolabial angle

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Pretreatment cephalometrics

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The treatment objectives wereTo correct proclination in both the archesTo correct canine cross bite on the right sideTo relieve the crowdingTo correct the dental midlineTo establish a Class I molar relationship and to maintain a Class

I canine relationshipTo obtain ideal overjet and overbite

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment ProgressOrthodontic tooth movement is initiated with 0022 slot MBT

bracket system in both the arches 0016 NiTi was the initial wire followed 0017 times 0025 NiTi 0019 times 0025 NiTi 0019 times 0025 SS In the maxillary arch premolars and canines retracted separate followed by upper anterior retraction In the mandibular arch en masse retraction was carried out

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post treatment extra oral and intraoral photo

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Three years after retention

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

FIRST MOLARExtraction of First molars are regarded as the cornerstones of dental arches and are considered to play a key role in the establishment of occlusion by Angle They are usually not extracted unless otherwise indicated

Extraction of first molars is avoided becausebull It does not give adequate space to relieve anterior crowdingbull Deepening of bitebull Poor a proximal contact between second premolar and second molarbull Second premolar and second molar may tip into extraction spacebull Mastication is affected

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Indications1 Minimum space requirement for correction of anterior crowding or mild proclination2 Grossly decayedperiodontally compromised molar with poor prognosis 3 Impacted molar-rarely seen4 First molars are extracted when they are grossly decayed or heavily filled First permanent molars are highly susceptible to dental caries especially during childhood immediately after their eruption5 Extraction of first molars may be advantageous in open bite cases as this may lead to deepening of the bite

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case report first molar extraction in four quadrantsA 12-year-old female who presented with a Class I malocclusion on a Skeletal I base having an average maxillaryndashmandibular planes angle and slightly increased lower facial height She had moderate upper and lower crowding and her first molars had suffered previous caries Treatment was carried out using fixed appliances with reinforced anchorage and first molars were extracted in all four quadrants

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Pretreatment photo

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment planOral hygiene and dietary advice Upper palatal arch to upper second

molars with anterior Nance button Extraction of the upper and lower first molars left and right Upper

and lower fixed appliances using pre-adjusted Edgewise system Upper removable wrap around retainer Lower bonded retainer

The 4 first molars were extracted to relieve the upper and lower crowding

Three of these teeth were heavily restored and had a poor long-term prognosis

Because of this the first molars were chosen instead of first premolars which would normally have been the extraction choice being nearer to the site of crowding

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment planNance button was fitted to bands on the fully erupted second

molars This would maintain sufficient upper first molar space for

correction of the malocclusion The 4 first molars were extracted the lower second molars banded

and all the remaining teeth were bonded with brackets of 0022x0028-inch slot size Andrewrsquos prescription

Initial alignment was carried out with upper and lower 0016-Ni Ti wires using stainless Steel tubing to protect the wires in the extraction sites and lace-backs in all 4 quadrants

Space was created for the lower lateral incisors by the use of a NiTi coil spring on a lower 0018-inch stainless steel round wire

Subsequently a 0012-inch nickel-titanium piggy-back arch wire was used to align the lateral incisors to the base arch wire

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post-treatment extra-oral

photographs

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

After full expression of the round nickel titanium wires

0018x0025-inch rectangular nickel titanium wires were placed

and followed by upper and lower 0019x0025-inch stainless steel

working wires to allow final space closure

Intra-arch nickel-titanium closed-coil springs in all four quadrants

were used for space closure after removal of the upper palatal arch

dead ligatures were used to maintain space closure whilst upper

and lower 0014-inch stainless steel wires were placed with minor

bends to allow final tooth positioning

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post-treatment intra-oral photographs

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

No inter-arch elastics were used as this might have reduced the overbitenickel-titanium closed-coil springs in all four

Following debond an upper removable wrap around retainer was provided for 3 months full-time wear

6 months night time wear and a lower 00175-inch annealed twist flex retainer was bonded lingually to the lower incisors and canines

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post-treatment intra-oral photographs

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction molars

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case reports extraction first lower molarThe patient male 13 years and four months old

presented for initial examination with the chief complaint of maxillary incisor protrusion

He had no sucking or postural habits and had normal swallowing and speech Regarding oral health

His mandibular first molar crowns were significantly destroyed

The mandibular second molars and maxillary first molars showed carious lesions on the occlusal surface and the presence of dental calculi and gingivitis was observed

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Pretreatment photo

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

TREATMENT PLAN The treatment plan provided for extraction of the

mandibular first molars given their crown destruction and need of endodontic treatment and prosthetic rehabilitation which would be convenient to avoid in such a young patient

In order to maintain mechanics symmetry while not depending heavily on patient compliance maxillary first molar extractions were also planned

The planned retention consisted of a removable maxillary retainer and an canine to canine bonded lingual retainer in the mandibular arch

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Post treatment photo

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction Mandibular second molarsMandibular second molar is positioned at the end of the dental

arch and therefore is away from the site of crowding Its extraction does not help in relieving the crowding however extraction may be indicated in the following cases

second molar extraction allows distal movement of the first permanent molar This provides enough space for premolar eruption

To relieve impaction of mandibular third molar Since the position of eruption of third molar is variable extraction of second molar is not usually indicated to relieve third molar impaction

To prevent lower incisor crowding evidence shows that patients with lower second molar extraction suffered less lower arch shortening

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

To correct mild to moderate arch length deficiencies existing with good facial profiles

Severely carious ectopically erupted or severely rotated second molar

Open bite cases extraction may help in correcting the anterior open bite

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Mechanism of extraction of lower second molarsin correction of skeletal Class III malocclusion

To correct anterior crossbites and normalize molar relationship the upper arch should move forward and the lower arch backward Therefore extractions in the upper arch may be undesirable Extraction of lower teeth mesial to the first molars might aid correction of the anterior crossbite but it might also be unfavorable to the correction of molar relationship Furthermore occlusal interlocking of all eight premolars might increase stability after orthodontic therapy which is crucial to treatment of Class III malocclusion

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction of the lower second molars may be a useful treatment option in the management of severe Class III malocclusion However such treatment should be carried out after detailed evaluation of third molar position etc Although extraction of lower second molars provides enough space to move the lower arch backward compared with the extraction of lower third molars it has little advantage on relieving crowding in the lower anterior segments Therefore to identify the indication of extraction of lower second molars in correction of severe Class III malocclusion is the key for the success of the treatment

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case Report Lower Second Molar ExtractionA 12-year-old girl presented with an anterior crossbite and a concave profile A concave facial profile was present in combination with a retrusive maxilla and a protrusive mandible with no mandibular displacement Surgical correction of the skeletal deformity and facial profile was recommended but the patient refused the procedure and insisted on an orthodontic correction

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The intraoral examination showed a complete Class III molar relationship on the right side and a super Class III molar relationship on the left side A crossbite of left maxillary second premolar to right maxillary second premolar was noted

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

A Tip-Edge straight-wire appliance was initiated after extraction of the lower second molars After 4 months of Class III elastics the anterior crossbite was corrected Ten months later a Class I molar relationship was established At the end of treatment the patient showed a straight profile normal overbite and overjet

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The superimposition of pretreatment and posttreatment cephalogram tracings revealed that the retroclination of the lower anterior teeth had changed to a mean of 118 degree A skeletal Class III tendency remained after the treatment with an ANB of 068 degree but the facial profile showed a significant improvement A follow-up panoramic radiograph showed complete eruption of the lower third molars

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

bullSuccess in treatment of the some severe Class III deformity in permanent dentition could be achieved with fixed appliance and extraction of lower second molars bull Fixed appliance in combination with extraction of lower second molars allowed tipping movement of teeth in a larger range and definite and limited skeletal change bull Remarkable soft-tissue change was noted after extraction of lower second molars and concave facial profile changed to straight profile bull Eruption of lower third molar should be the follow-up after extraction of lower second molar

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Extraction mandibular second molar

>

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

pretreatment

posttreatment

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

MAXILLARY SECOND MOLARSIndications1 In mildly crowded cases where less than 3-4 mmspace is required for the labial segments 2 To make space for crowded second premolar bydistalization of first molar 3 When second molar is impacted against first molar second molar extraction is preferred over extraction of severely impacted third molar for which there is no space in the line of occlusion

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Criteria for maxillary second molar extraction and replacement by third molar bull The chronologic and dental age of the patient should be past

the average time when second molars would eruptbull Size shape and root area of third molar should be sufficient to serve in place of second molarbull Maxillary tuberosity should be insufficient to accommodate all 3 molarsbull If second molar is in buccal occlusion and third molar is positioned in the tuberositybull Maxillary third molar in favorable angulation for eruptionbull Second molar severely carious with questionable prognosis

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Contraindications1 Maxillary third molars positioned high in the

tuberosity2 Poor angulation in relation to second molar3 Undersized crown or roots4 Third molar bud is absent

TimingMaxillary second molar should be extracted when the third

molar has migrated sufficiently in the alveolar bone so that the

occlusal surface is approximately level with the vertical midline

of the second molar root

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Advantages of second molar extractionbull Facilitates treatment using removable appliancesbull Eruption of third molar is fasterbull Prevention of dished-in appearance of the facebull Few residual spaces at the end of treatmentbull Good mandibular arch formbull Less chances of relapsebull Increases overbite hence in open bite cases

Disadvantagesbull Too much tooth substance is removed in mild crowding casesbull Extraction site away from area of crowding

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Case report extraction upper second molar Female patient aged 17 years and 1 month who sought

orthodontic treatment complaining of lack of space for her canines

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

A clinical examination showed a slightly asymmetrical face lip asymmetry (increased muscle contraction on the left side) lip seal at rest a low smile line and asymmetry when raising the lips mesocephalic facial pattern balanced facial thirds and convex profile

Case Report extraction upper second molar

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Intra oral photo An intraoral examination revealed parabolic shaped arches

Class II relationship of molars and canines 4 mm overjet 50 overbite upper left second premolar and lower left first premolar in crossbite light curve of Spee lower midline shifted 05 mm to the right severe crowding in the upper arch (-11 mm discrepancy) and crowding in the lower arch (-5 mm discrepancy

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Intra oral photo

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The radiographs confirmed the presence of intraosseous third molars with normal anatomy The upper third molars had fully formed crowns with two-thirds of root formation The lower third molars were impacted Supernumerary teeth were also present (Fourth right and left lower molars and fourth right upper molar) and visible lack of space for correct positioning of the upper canines

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment plan In order to establish a Class I molar relationship as

soon as possible and because the patient did not exhibit any growth potential we opted for upper second molar extraction to facilitate distalization of the upper first molar and class II correction

Additionally we also extracted the lower third molars that were impacted and the lower supernumerary teeth We decided against extracting the upper supernumerary molar given the possibility of damage to the third molar when doing so The extraction of this tooth was postponed to a future more convenient occasion

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Treatment plan After extraction the upper first molars were banded and a

cervical traction headgear was installed (350 g - 16 h day) for first molar distalization which was achieved after a period of four months

The first upper and lower premolars were extracted to address the severe crowding and the protrusion Subsequently brackets were bonded to the lower second premolars canines and central incisors Brackets were not bonded to the upper and lower lateral incisors on account of the crowding We used 0016-in Multi loop Tweed style archwires to correct canine mesiobuccal inclination

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

Final facial photographs

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

After alignment and leveling the canines were retracted with chain elastics Brackets were then bonded to the lateral incisors followed by realignment and releveling

Any residual space was then closed by retraction of the upper and lower incisors using rectangular archwires with bull loops

Twenty-two months after the extraction of the second molars third molars were erupted and ready for banding or bonding

After treatment completion an upper wrap-around removable appliance and a fixed lower canine-to-canine lingual arch were installed for retention

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

ResultsThe patients extraoral aspect remained as it was initially

(Fig 5) except for her profile which had its convexity reduced

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

The radiographs disclosed adequate root parallelism Moreover upper third molars were found to be appropriately positioned At this time the removal of the supernumerary upper molar was

performed) Fig 7(

From a cephalometric standpoint the skeletal pattern was maintained The most significant changes occurred in the upper and lower incisors and lips The upper and lower incisors were retracted Thus correction of the dental double protrusion was achieved by moving the incisors to their original position Due to these dental changes the lips were retracted reducing the patients profile convexity (Figs 5 and 8 and Table

Third molar Extraction of third molar during orthodontic treatment does not yield space for de crowding or reduction of proclination

INDICATIONS1 The conventional timing of extraction of a third molar is when two-thirds of its root is formedExtraction of third molar should not be delayed becausebull More difficult to remove when roots are completedbull Danger of root dilacerations which may make remova I more difficultbull Pericoronitis can develop and cause bone loss and pocket formation may occur distal to second molar

INDICATIONS2 Erupting mandibular third molars have been

implicated to be the cause of late lower anterior crowding although the evidence is not clear cut

However it is difficult to detect such a force In fact late anterior crowding often develops in individuals whose lower third molars are congenitally missing

3 Malformed third molars which interfere with normal occlusion should be extracted

Case report mandibular third extraction

The 13-year-old patient in good general health Her main complaint was related to the presence of anterior cross bite and ectopic eruption of tooth 13 Despite protrusion of the lower lip and little exposure of the upper lip facial esthetics did not seem to be a concern to the patient A more detailed examination of occlusion showed the presence of premature contact of the incisors in a centric relation leading to a more anterior position of the mandible in centric occlusion Her mother had reported no Class III malocclusion family history so the peculiarities involved in this case point to a multifactorial etiology

DIAGNOSISThe patient presented significant skeletal discrepancy with ANB angle equal to -3deg (SNA = 82deg and SNB = 85deg) with good vertical mandibular growth direction (SN-GoGn = 31deg)

With regard to the tooth aspect the patient presented Angles Class III malocclusions with anterior cross bite 1 mm overjet 50 overbite and retroinclined mandibular and maxillary incisors When handling the mandible in centric relation premature contact was found in the incisor region which led to functional deviation in the anterior direction that accentuated the Class III malocclusion Furthermore moderate anterior-superior crowding tooth 13 in palato-version and the mandibular and maxillary midlines coinciding with each other were also found (Figs 1 and 2) When analyzing the facial characteristics the patient presented a mesocephalic face with a concave profile proportional facial thirds lip competence and absence of significant asymmetries The lower lip was slightly more protrusive than the upper lip panoramic radiographs (Fig 3) did not show any significant

alteration that would be contraindication to orthodontic treatment

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

Third molar Extraction of third molar during orthodontic treatment does not yield space for de crowding or reduction of proclination

INDICATIONS1 The conventional timing of extraction of a third molar is when two-thirds of its root is formedExtraction of third molar should not be delayed becausebull More difficult to remove when roots are completedbull Danger of root dilacerations which may make remova I more difficultbull Pericoronitis can develop and cause bone loss and pocket formation may occur distal to second molar

INDICATIONS2 Erupting mandibular third molars have been

implicated to be the cause of late lower anterior crowding although the evidence is not clear cut

However it is difficult to detect such a force In fact late anterior crowding often develops in individuals whose lower third molars are congenitally missing

3 Malformed third molars which interfere with normal occlusion should be extracted

Case report mandibular third extraction

The 13-year-old patient in good general health Her main complaint was related to the presence of anterior cross bite and ectopic eruption of tooth 13 Despite protrusion of the lower lip and little exposure of the upper lip facial esthetics did not seem to be a concern to the patient A more detailed examination of occlusion showed the presence of premature contact of the incisors in a centric relation leading to a more anterior position of the mandible in centric occlusion Her mother had reported no Class III malocclusion family history so the peculiarities involved in this case point to a multifactorial etiology

DIAGNOSISThe patient presented significant skeletal discrepancy with ANB angle equal to -3deg (SNA = 82deg and SNB = 85deg) with good vertical mandibular growth direction (SN-GoGn = 31deg)

With regard to the tooth aspect the patient presented Angles Class III malocclusions with anterior cross bite 1 mm overjet 50 overbite and retroinclined mandibular and maxillary incisors When handling the mandible in centric relation premature contact was found in the incisor region which led to functional deviation in the anterior direction that accentuated the Class III malocclusion Furthermore moderate anterior-superior crowding tooth 13 in palato-version and the mandibular and maxillary midlines coinciding with each other were also found (Figs 1 and 2) When analyzing the facial characteristics the patient presented a mesocephalic face with a concave profile proportional facial thirds lip competence and absence of significant asymmetries The lower lip was slightly more protrusive than the upper lip panoramic radiographs (Fig 3) did not show any significant

alteration that would be contraindication to orthodontic treatment

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

INDICATIONS2 Erupting mandibular third molars have been

implicated to be the cause of late lower anterior crowding although the evidence is not clear cut

However it is difficult to detect such a force In fact late anterior crowding often develops in individuals whose lower third molars are congenitally missing

3 Malformed third molars which interfere with normal occlusion should be extracted

Case report mandibular third extraction

The 13-year-old patient in good general health Her main complaint was related to the presence of anterior cross bite and ectopic eruption of tooth 13 Despite protrusion of the lower lip and little exposure of the upper lip facial esthetics did not seem to be a concern to the patient A more detailed examination of occlusion showed the presence of premature contact of the incisors in a centric relation leading to a more anterior position of the mandible in centric occlusion Her mother had reported no Class III malocclusion family history so the peculiarities involved in this case point to a multifactorial etiology

DIAGNOSISThe patient presented significant skeletal discrepancy with ANB angle equal to -3deg (SNA = 82deg and SNB = 85deg) with good vertical mandibular growth direction (SN-GoGn = 31deg)

With regard to the tooth aspect the patient presented Angles Class III malocclusions with anterior cross bite 1 mm overjet 50 overbite and retroinclined mandibular and maxillary incisors When handling the mandible in centric relation premature contact was found in the incisor region which led to functional deviation in the anterior direction that accentuated the Class III malocclusion Furthermore moderate anterior-superior crowding tooth 13 in palato-version and the mandibular and maxillary midlines coinciding with each other were also found (Figs 1 and 2) When analyzing the facial characteristics the patient presented a mesocephalic face with a concave profile proportional facial thirds lip competence and absence of significant asymmetries The lower lip was slightly more protrusive than the upper lip panoramic radiographs (Fig 3) did not show any significant

alteration that would be contraindication to orthodontic treatment

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

Case report mandibular third extraction

The 13-year-old patient in good general health Her main complaint was related to the presence of anterior cross bite and ectopic eruption of tooth 13 Despite protrusion of the lower lip and little exposure of the upper lip facial esthetics did not seem to be a concern to the patient A more detailed examination of occlusion showed the presence of premature contact of the incisors in a centric relation leading to a more anterior position of the mandible in centric occlusion Her mother had reported no Class III malocclusion family history so the peculiarities involved in this case point to a multifactorial etiology

DIAGNOSISThe patient presented significant skeletal discrepancy with ANB angle equal to -3deg (SNA = 82deg and SNB = 85deg) with good vertical mandibular growth direction (SN-GoGn = 31deg)

With regard to the tooth aspect the patient presented Angles Class III malocclusions with anterior cross bite 1 mm overjet 50 overbite and retroinclined mandibular and maxillary incisors When handling the mandible in centric relation premature contact was found in the incisor region which led to functional deviation in the anterior direction that accentuated the Class III malocclusion Furthermore moderate anterior-superior crowding tooth 13 in palato-version and the mandibular and maxillary midlines coinciding with each other were also found (Figs 1 and 2) When analyzing the facial characteristics the patient presented a mesocephalic face with a concave profile proportional facial thirds lip competence and absence of significant asymmetries The lower lip was slightly more protrusive than the upper lip panoramic radiographs (Fig 3) did not show any significant

alteration that would be contraindication to orthodontic treatment

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

DIAGNOSISThe patient presented significant skeletal discrepancy with ANB angle equal to -3deg (SNA = 82deg and SNB = 85deg) with good vertical mandibular growth direction (SN-GoGn = 31deg)

With regard to the tooth aspect the patient presented Angles Class III malocclusions with anterior cross bite 1 mm overjet 50 overbite and retroinclined mandibular and maxillary incisors When handling the mandible in centric relation premature contact was found in the incisor region which led to functional deviation in the anterior direction that accentuated the Class III malocclusion Furthermore moderate anterior-superior crowding tooth 13 in palato-version and the mandibular and maxillary midlines coinciding with each other were also found (Figs 1 and 2) When analyzing the facial characteristics the patient presented a mesocephalic face with a concave profile proportional facial thirds lip competence and absence of significant asymmetries The lower lip was slightly more protrusive than the upper lip panoramic radiographs (Fig 3) did not show any significant

alteration that would be contraindication to orthodontic treatment

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

With regard to the tooth aspect the patient presented Angles Class III malocclusions with anterior cross bite 1 mm overjet 50 overbite and retroinclined mandibular and maxillary incisors When handling the mandible in centric relation premature contact was found in the incisor region which led to functional deviation in the anterior direction that accentuated the Class III malocclusion Furthermore moderate anterior-superior crowding tooth 13 in palato-version and the mandibular and maxillary midlines coinciding with each other were also found (Figs 1 and 2) When analyzing the facial characteristics the patient presented a mesocephalic face with a concave profile proportional facial thirds lip competence and absence of significant asymmetries The lower lip was slightly more protrusive than the upper lip panoramic radiographs (Fig 3) did not show any significant

alteration that would be contraindication to orthodontic treatment

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

Figs 1 and 2

Fig 3

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

OBJECTIVES OF THE TREATMENTThe modified Haas expander device was used in the maxillary

arch with bands on the first pre-molars and molars that were also encapsulated in the posterior region Standard metal brackets were then bonded without torque or angulation using the 0022 x 0028-in slot edgewise system In the mandibular arch in addition to the fixed appliance a J-Hook high-pull headgear was used

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

Post treatment

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

The Role of Mandibular Third Molars on Lower Anterior Teeth Crowding and Relapse after Orthodontic Treatment A Systematic ReviewKhalid H Zawawi and Marcello Melis ( 2014 )They concluded that the role of the third molars in the development of anterior tooth crowding cannot be drawn A high risk of bias was found in most of the trials and the outcomes were not consistent However most of the studies do not support a cause-and-effect relationship therefore third molar extraction to prevent anterior tooth crowding or postorthodontic relapse is not justified

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

Third molars and dental crowding different opinions of orthodontists and oral surgeons among Italian practitioners

Michela Gavazzi et al (2014) Studied role of third molars in causing of incisor crowding especially in the lower arch continues to be controversial The aim of this work is to compare opinions of Italian oral surgeons and orthodontists on this topic Italian orthodontists and oral surgeons have the same opinion on the role of the third molar in causing anterior crowding The study concluded that majority of both groups of clinicians do not consider their preventive extraction useful in order to prevent anterior crowding

Thank you

• Slide 1
• Slide 2
• Slide 3
• Extraction teeth for gaining space in orthodontics
• Slide 5
• THE NEED FOR EXTRACTION
• Slide 7
• Arch Length-Tooth Material Discrepancy
• Correction of Sagittal Interarch Relationship
• Correction of Sagittal Interarch Relationship
• Extraction for the Relief of Crowding
• CHOICE OF TEETH FOR EXTRACTION
• INCISORS
• Case report central incisors
• Slide 15
• Treatment plane
• Treatment plane (2)
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Indications lower incisor extraction
• Slide 23
• Indications lower incisor extraction (2)
• contraindications
• Case Report
• Slide 27
• Slide 28
• Slide 29
• Post treatment
• Conclusion
• CANINES
• Indications
• Case report (1) canine
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Case report (2) canine
• Pretreatment photo
• Slide 41
• Treatment option
• The Power-Scope has several advantages over Class II elastics
• Post treatment photo
• Slide 46
• Slide 47
• FIRST PREMOLARS
• Extraction first premolars
• Indications
• Slide 51
• Timing of Extraction
• Case reports
• Slide 54
• Treteatment plane
• Slide 56
• Slide 57
• SECOND PREMOLARS
• Case reports
• Pretreatment extra oral and intraoral photo
• Pretreatment
• Pretreatment cephalometrics
• The treatment objectives were
• Treatment Progress
• Post treatment extra oral and intraoral photo
• Three years after retention
• FIRST MOLAR
• Indications (2)
• Case report first molar extraction in four quadrants
• Slide 70
• Treatment plan
• Treatment plan (2)
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Extraction molars
• Case reports extraction first lower molar
• Pretreatment photo
• Slide 81
• TREATMENT PLAN
• Post treatment photo
• Slide 84
• Slide 85
• Extraction Mandibular second molars
• Slide 87
• Mechanism of extraction of lower second molars in correction of
• Slide 89
• Case Report Lower Second Molar Extraction
• Slide 91
• Slide 92
• Slide 93
• bull Success in treatment of the some severe Class III deformity i
• Extraction mandibular second molar
• Slide 96
• MAXILLARY SECOND MOLARS
• Slide 98
• Contraindications
• Advantages of second molar extraction
• Case report extraction upper second molar
• Intra oral photo
• Intra oral photo
• The radiographs confirmed the presence of intraosseous third mo
• Treatment plan
• Treatment plan
• Final facial photographs
• Slide 109
• Results
• The radiographs disclosed adequate root parallelism Moreover
• Slide 112
• Third molar
• INDICATIONS
• Case report mandibular third extraction
• Slide 116
• DIAGNOSIS
• Slide 118
• Slide 119
• OBJECTIVES OF THE TREATMENT
• Slide 121
• Slide 122
• The Role of Mandibular Third Molars on Lower Anterior Teeth Cro
• Third molars and dental crowding different opinions of orthodo
• Slide 125