Extraction in the Mixed Dentition

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A Reasonable Alternative for Extraction in the Selected Patients? Mixed Dentition ─

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I declare that neither I, nor any member of my “War of Roses” Tennessee family, has a financial arrangement or affiliation Governor's Race 1886 with any corporate organization which offers financial support or grant monies for this continuing education presentation, nor do I have a financial interest in any commercial product(s) or services I will discuss in this presentation.

The Taylor Brothers 3 4

5 N. Nash

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N. Nash N. Nash

N. Nash Pretreatment FMIA 70 FMA 20 Options IMPA 90 SNA 83 1.Space Management SNB 80 ANB 3 2.Expansion – Arch AO-BO 4mm Development OCC 0 Z 90 3.Extraction in the Mixed Dentition

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But ─ Before Options Are Considered ─ How Much Space Is Needed?

How Much Space is Needed? 13

Totals

4mm Maxillary Arch 4mm Space Required 16.5mm Space Available 8.0mm 20.0mm 18.5mm Deficit 8.5mm

Mandibular Arch Space Required 46.1mm Space Available 38.5mm Space Available Deficit 7.6mm 16

Option Maxillary Arch ─ Must Space Have 8.5mm 4mm 4mm Management No Space to Manage

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Space Management Space Management Mandibular Arch Left side ─ Plus Yes 20.0mm 18.5mm Right side Interproximal - 4.6mm Reduction? ? 19 20

Space Needed Option Maxillary Arch ─ 8mm Mandibular Arch ─ 7.6mm Make Space for Interproximal the Teeth Reduction??? 21 22

Make Space for the Teeth Expansion ─ Arch Development Does Our Science Space Space Need to be Consulted?

N. Nash Yes! 24

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Sinclair and Little (1983) • Sinclair and Little (1983) Reported on a Sample of 65 Subjects With Normal What Happens Occlusions For Changes in the Dental Arch From the Mixed Dentition, to Early Permanent Dentition, and into Early With No Adulthood. • Arch Length Decreased From the Mixed Treatment? Dentition into Early Adulthood While Incisor Irregularity Increased From 13 to 20 Years of Age. 25 26

Richardson (1999) Does Arch Length Inevitably Decrease From Mixed Dentition to Adult Dentition? • Evaluated the Changes in Alignment in the Untreated Lower Arch at Various Barrow & White, AJO 1952 Developmental Stages: 7 to 15 Years, 13 to Brown, et al, Act. O Scand 1951 18 Years, 18 to 21 Years, and 18 to 50 Little, et al, AJO 1990 Years. Lundstrom, Dent Pract 1969 • After Evaluation of the Dental Arch at Moyers, HandBK of Ortho 1985 Yes! Various Developmental Stages, Richardson Moorees, Harv Univ Press 1959 (1999) Concluded That the Greatest Nance, AJO 1947 Increase in Amount of Lower Incisor Sinclair, et al, AJO 1983 Crowding Occurs Between the Ages of 13 Sillman, AJO 1964

and 18 Years of Age (= 2.3 mm). 27 28

When Mandibular Incisors Are Proclined During Treatment, Do They Tend to Upright? What Happens Nance, AJO 1947 Mills, Brit Ortho Jrn 1966 Litowitz, Angle Ortho July-Oct 1948 With Cole, Angle Ortho July-Oct Hixon, AJO 42:898, 1956 Yes! Hixon, Angle Ortho 42:200, 1972 Treatment? Weinstein, Angle Ortho 33: 1, 1963 Miller, U of Oregon Thesis 1971 Boley, UMKC Thesis 1966 29 30

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de la Cruz A, Sampson P, Little RM, Artun J, Shapiro PA. Do Expanded Mandibular Canines Long-term Changes In Arch Form After Orthodontic Treatment And Retention. Am J Orthod Dentofacial Orthop. 1995 May; Typically Constrict After the Removal of 107(5):518-30. Retention? Bishara, et al, AJO1989 • Arch form tended to return toward the Glenn, et al, AJO 1987 pretreatment shape after retention. Little, et al, AJO 1981 • Greater the treatment change, the greater the McCauley, AJO 1944 tendency for postretention change. Riedel, Angle Ortho 1966 Yes! • However, individual variation was considerable. Sandusky, Thesis 1983 Shapiro, AJO 1974 • Patient's pretreatment arch form appeared to be Sondhi, et al, AJO 1980 the best guide to future arch form stability. Steadman, Angle Ortho 1961 Strang, Angle Ortho 1949, 1952 31 32

Kahl-Nieke B, Fischbach H, Schwarze CW. Post-retention El-Mangoury NH. Orthodontic Relapse In Subjects With Varying Crowding And Incisor Irregularity: A Long-term Follow-up Degrees Of Anteroposterior And Vertical Dysplasia. AJO/DO, Vol. 75, Evaluation Of Stability And Relapse. Orthod. 1995 #5, May 1979, pp 548-561. Aug;22(3):249-57. • In both the- stable and the relapse groups, the mandibular intercanine width decreased postretention. This decrease was associated more Over expansion was found to be a with the relapse group than with the stable group. • The mandibular intercanine width tended to relapse factor in mandibular incisor toward its original pretreatment value. This suggests that, at the end of active treatment, the mandibular relapse. intercanine width should be maintained as originally presented. • There was no significant interaction between orthodontic relapse (or stability) and whether or not extraction was included as a part of the mechanotherapy.

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Little RM, Riedel RA, Enqst ED. Serial extraction of first premolars- postretention evaluation of stability and relapse. Angle Orthod. 1990 Winter;60(4):255-62. The Washington Studies Should • Twenty-two of the 30 cases (73%) demonstrated clinically Not Be Interpreted to Mean That unsatisfactory mandibular anterior alignment postretention. • Intercanine width and arch length decreased in 29 of the 30 cases by the postretention stage.

Artun J, Garol JD, Little RM. Long-term stability of mandibular incisors The Position of the Teeth following successful treatment of Class II, Division 1, malocclusions. Angle Orthod. 1996;66(3):229-38. Does Not Matter • At post-retention, 9.0% had irregularity index values of 6.5 mm or more and 47.4% had values equal to 3.5 mm or less. • Treatment increase of intercanine width and post-retention decrease of intercanine width and arch length were associated with relapse. 35 36

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There Are No Studies of Patients Treated With Treatment Plan With Expansion Who Have Been Recalled Twenty Five Years Strang, Nance, Tweed, After Treatment Merrifield, Mangoury, Blake & Bibby, & Boley! So — What Should We Do? 37 38

Strang, R.H.W. “The Fallacy Of Denture Tweed, CH. “Indication for the Expansion As A Treatment Procedure.” Extraction of Teeth in Orthodontic The Angle Orthodontist, 1949: 49: 12 - Procedures,” AM J of Ortho Oral Surg 17. 30:405, 1944.

Nance, H. “The Limitations of Orthodontic Tweed, CH. “A Philosophy of Treatment”, Am J of Ortho & Oral Surg Orthodontic Treatment”, Am J of Ortho 33:253-301, 1947. & Oral Surg 31:74, 1945.

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Merrifield, LL. “The Dimension Boley JC, Mark JA, Sachdeva RC, Buschang PH. of the Denture: Back to the "Long-term stability of Class I premolar extraction treatment." Am J Orthod Dentofacial Orthop. 2003 Basics,” AJO/DO Vol106:535, Sep;124(3):277-87. 1994.

Paquette DE, Beattie JR, Johnston LE Jr. "A long- Merrifield, LL. “Differential term comparison of nonextraction and premolar extraction edgewise therapy in "borderline" Class II Diagnosis,” Seminars in patients." Am J Orthod Dentofacial Orthop. 1992 Orthodontics #2, 241, 1996. Jul;102(1):1-14.

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The Face ─ It Can!

Does Expansion Many Times It Compromise Facial Does Esthetics?

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Expansion Can Harm Is There An Facial Esthetics ANTERIOR LIMIT OF THE DENTITION?

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Merrifield’s Z Angle

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Tweed, CH. “The Frankfort Mandibular Incisor Angle (FMIA) In Orthodontic Diagnosis, Treatment Planning and Prognosis”, Am J of Ortho & Oral Surg 24:121, 1954.

Burrow, SJ. “Smile Esthetics After Orthodontic Treatment With and STEINER Without Extraction of Four First Premolars,” Seminars in Orthod, Vol 18, #3, Sept 2012 pp 201-209. 49 50

Expansion – Arch Development Maxillary Arch ─ Must have 8.5mm Now ─

4mm 4mm Some Specific Questions

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─ Yes ─ Can We Expand the But Should We? Maxillary Arch?

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Adkins MD, Nanda RS, 1mm of Lateral Expansion Currier GF. Arch Perimeter Changes on Rapid Palatal Yields .66 mm of Arch Expansion. Am J Orthod Perimeter Gain Dentofacial Orthop. March 1990;97(3);194-199. Expansion Required ≈ 12mm

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Schiffman PH, Tuncay OC. Maxillary expansion: a meta analysis. Clin Ortho Res, Gianelly AA. Rapid Palatal 2001 May;4(2); 86-96. Expansion in the Absence of The mean expansion after adjustment according to Crossbites: Added Value? the principles of meta analysis was 6.00 mm with a standard deviation of 1.29 mm. Of the 6-mm average, Am J Orthod Dentofacial 4.89 mm was retained while wearing retainers… Finally, in the long-term post-retention study period Orthop. October 2003; only 2.4 mm of the residual expansion was reported to have remained. This 2.4 mm of expansion 124(4);362-365. remaining after more than a year or more of postretention period was no greater than what has been documented as normal growth. 57 58

If We Expand the Gianelly – “One conclusion is Maxillary Dentition in the that the use of the maxillary arch as the template for the Absence of Crossbite ─ mandibular arch might We MUST EXPAND jeopardize the stability of the the Mandibular mandibular arch by expanding it in areas that are known to be Dentition unstable.” 59 60

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Burke SP, Silveira AM, Is It Prudent to Goldsmith LJ, Yancey JM, Van Stewart A, Scarfe WC. “A Expand the Meta-Analysis of Mandibular Intercanine Width in Treatment Mandibular and Postretention", Angle Ortho. February 1998; 68:53- Dentition? 60. 61 62

Conclusion – Lateral Maxillary Burke et al Performed a Expansion is Probably Not a Meta-Analysis of 26 Articles – Good Solution for Our Patient Evaluated 1233 Patients

4mm Conclusion: Most Prudent 4mm Course Is to Maintain the Original Intercanine Dimension

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Lateral Mandibular Expansion is Not a What About Prudent Option Moving the Teeth Distally?

20.0mm 18.5mm Not Laterally?

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THE POSTERIOR LIMIT OF Is There a THE DENTITION Posterior Limit of the Dentition? Yes!!

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This Patient is 17 years old.

A Modern “Widget” The second molars are impacted due to distalization mechanics. 69 70

We Can Easily Push the AJO/DO Vol 146, No 2 Maxillary Teeth Distally But What About the Mandibular Teeth?

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What About Maintaining the Position of the Mandibular Posterior Teeth?

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14 Months into Treatment

K. Cox K. Cox 75 76

AJO/DO Vol 141, No 2

K. Cox 77 78

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300 Patients ─ Four Groups

– Schwarz Rebecca Lash Rubin, Tiziano Baccetti, and James A. McNamara, Jr – Lingual holding Arch – Combination of Schwarz & Holding Arch – Control

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Findings / Conclusions Findings / Conclusions Orthodontic Appliances “All 3 Treatment Groups Intended to Maintain Arch Had a Higher Incidence Perimeter in the Mixed of Mandibular Second Dentition Increase the Molar Eruption Difficulty Probability of Eruption Disturbances of the When Compared with the Controls.” Mandibular Second Molars. 81 82

“Most Often the Arch Length Gain Occurs by Lower Incisor The Bottom Line Proclination and/or An Increase in Intercanine Width, Both Being on Arch NOTORIOUSLY Unstable.”

Development David Kennedy Early Treatment Options PCSO Bulletin – Summer 2010 83 84

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Bowman SJ. “Pulsus a Mortuus Equus” Lysle E. Johnston Jr (Beating a Dead Horse)

Seminars in Orthodontics, Vol 20, MORE Bone or #1, 2014, pp 36-45. LESS Teeth! Arguments About Age – Appropriate Arch Length Alternatives. That is the Choice! 87 88

Peck, Sheldon. “The Current Fashion of Nonextraction Dental Arch Expansion in Orthodontics: A Critique” Seminars in Orthodontics, Vol 18, #2, June 2012, pp 126-127. Arch Development

Today, conscientious orthodontists are Little RM, Riedel RA, Stein A. being challenged by commercially Mandibular Arch Length Increase During marketed appliance systems that promise Mixed Dentition: Postretention easy solutions and are based on Evaluation of Stability and Relapse. Am nonextraction dental arch expansion. This J Ortho Dentofacial Orthop. May is a throwback to orthodontic methods 1990:97 (5):393-404. advocated a century ago, long before the evidence-based era of orthodontics, It is a FAILURE 87% radiography, and periodontology. 89 of the Time 90

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“…this strategy shows greater relapse than other samples we have collected.” Am J Orthod Dentofacial Orthop 2006; 130:202-13

Little RM, Riedel RA, Stein A. Mandibular arch length increase during the mixed dentition: postretention evaluation of stability and relapse. Am J Orthod Dentofacial Orthop. 1990; 97(5);393-404. 91 92

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Mandibular Arch Perimeter Decreased in Both Treated Samples What is the Best

95 Choice for Natalie?

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Options Option 1.Space Management 2.Expansion – Arch Extraction in the Development Mixed Dentition 3.Extraction in the Mixed Dentition

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..."It is better to have one or two teeth less in each jaw, provided it can be compensated by a suitable Age 6 arrangement, than to have the entire set of teeth poorly arranged and ill at ease…”

Bunon R. Essay sur las maladies des dents. Conference. In: Paris; 1743.

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“By sacrificing the (deciduous) In 1896, J.F. Colyer advocated extractions “to canine teeth to the incisors and gain room for the crowns and roots, to decrease mechanical treatment and in many the small molars (premolars) to the cases to abolish it as well as to relieve the (permanent) canines it will be pressure on the teeth and prevent caries, to possible to leave free space to improve the bite, and finally to have the teeth naturally assuming a better position”. make an attractive arrangement."

Bunon R. Essay sur las maladies des dents. Conference. In: Colyer J. Discussion on the early treatment of crowded Paris; 1743. mouths. Odont Soc Trans. 1896;28(2):215–33.

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Kjellgren B. Serial Extraction as a The phrase Serial Corrective Procedure in Dental Orthopedic Therapy, Eur. Orthod. Extraction has resulted in Soc. Trans p134, 1947–1948. the poorly planned removal of teeth by people Special Knowledge is who do not have the Required necessary knowledge. Jack Dale

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Hotz R. Guidance of eruption versus serial extraction, Am J “Guidance of Occlusion – Orthod 58:1, 1970. an even better term Hotz’s Guidance of Eruption because occlusion is the implies that knowledge of final destination of a tooth growth and development is that is erupting.” necessary to direct the teeth ─ Jack Dale as they erupt.

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This chapter is THE State of the Art work on extraction of This chapter is a teeth in the mixed dentition. MUST reference for • Fabulous Illustrations every clinical • Impeccably Referenced orthodontist. • Meticulous Explanations

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Graber TM. Serial extraction: a continuous diagnostic and decisional process. Am J Orthod. Heath J. The interception of 1971;60:541-75. malocclusion by planned serial extraction. New Zealand J. 1953;49:77-88.

Dewel BF. Serial extraction; its limitations and contraindications. Ariz Dent J. 1968;14(6):14-30.

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Dewel BF. Prerequisites in serial Lloyd ZB. Serial extraction as a extraction. Am J Orthod. 1969;55:533-9. treatment procedure. Am J Orthod. 1956;42:728-39. Dewel BF. Editorial. A question of terminology: serial extraction or Tweed CH. Treatment planning and guidance of eruption. Am J Orthod. therapy in the mixed dentition. Am J 1970;58:78-9. Orthod. 1963;49:881-906. Jacobs J. Cephalometric and clinical Dewel BF. Precautions in serial evaluation of class I discrepancy cases extraction. Am J Orthod. 1971;60:615-8. treated by serial extraction. Am J Orthod. 1965;51:401-11. 113 114

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Dale JG, Brandt S. Dr. Jack G. Dale on serial extraction. J Clin Orthod. Proffit WR. The timing of 1976;10(1):44-60. early treatment: an Dale JG, Brandt S. Dr. Jack G. Dale on overview. AM J Orthod serial extraction. 2. J Clin Orthod. 1976;10(2):116-36. Dentofac Orthop. 2006;

Dale JG, Brandt S. Dr. Jack G. Dale on 129:47-49. serial extraction. 3. J Clin Orthod. 1976;10(3):196-217.

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Prior to ANY A Careful Analysis Extraction Decision • Face • Skeletal Pattern Complete Records • Teeth Treatment Plan

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The Face The Face Mixed dentition Mixed dentition extraction procedures extractions are generally seem to work best when contraindicated in a the face has balance or is convex or concave face. at best, mildly protruded.

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The Face The Skeletal Pattern Vertical Dimension should be within NORMAL Limits 121 122

The Skeletal Pattern Mixed dentition extractions are generally contraindicated in patients with hyperdivergent or hypodivergent skeletal patterns. 123 124

The Skeletal Pattern The anteroposterior relationship of the maxilla to the mandible should be “normal.” If the mandible is either retrognathic or prognathic, mixed dentition extractions are generally not indicated. 125

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What About Mixed Dentition Proceed with Extraction in the Caution! Class II Dental Relationship? 127 128

Be Prepared to 1) Correct the Class II Molar Relationship with Mandibular Extraction 2) Treat to a Class I Canine / Class II Molar HB Byers

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HB Byers HB HB Byers 131 132

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HB Byers Byers HB 133 134

Dugoni SA. Comprehensive mixed dentition treatment. Am J Orthod Dentofac Orthop. 1998;113, p75–84.

Dugoni SA, Aubert M, Baumrind S. Differential diagnosis and treatment planning for early mixed dentition malocclusions. Am J Orthod Dentofac Orthop. 2006; 129, Issue 4, S80–S81.

HB Byers 135 136

Ringenberg Q. Serial extraction: Stop, look, and be certain. Am J Orthod. 1964;50:327–36. The Dentition Proffit WR. The timing of early treatment: an overview. Am J The Clinician MUST ascertain Orthod Dentofac Orthop. 2006;129:47–49. the space required and the Arch Length/Tooth Size Deficiency space available. • How much crowding would indicate that extractions of permanent teeth may be indicated? And  Other Factors? • 7mm or more of crowding was an indication (Ringenberg) • 10 mm or more of crowding (Proffitt)

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The Dentition Hixon EH, Oldfather RE. There are several methods that Estimation of the sizes of can be used to predict the unerupted cuspid and bicuspid space needed and the space teeth, Angle Ortho 28:236, 1958. required. Whatever the method of choice, Huckaba GW. Arch size analysis and tooth size prediction. Dent USE IT! Clin North Am 431, 1964.

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Gardner RA. “A Comparison of The “Dale” Method Four Methods of Predicting Arch Length” Am J Orthod, • Space Available vs Space Required 1979, 75(4) 387-398. • Curve of Spee Correction • Evaluation of Protrusion “Tanaka and Johnston Analysis (Its Correction Requires Space) seems to be the one most • Posterior Dentition Area Evaluation frequently used since it is a pure Jack Dale, Chapter 11

calculation.” 141 142

Therefore, a THOROUGH Study of:

The Face Age 9 The Skeletal Pattern The Dentition MUST Be Done in Order to Formulate a Mixed Dentition Extraction Treatment Plan.

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Four First Premolars Were Removed During the Mixed Dentition.

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Age 11

What is the Best

147 Choice for Natalie?

Four First Premolars and Mandibular Deciduous Teeth Were Removed

149 N. Nash

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N. Nash N. Nash

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N. Nash N. Nash

N. Nash Pretreatment N. Nash Progress N. Nash FMIA 70 FMIA 70 FMA 20 FMA 20 IMPA 90 IMPA 90 SNA 83 SNA 83 SNB 80 SNB 80 ANB 3 ANB 3 AO-BO 4mm AO-BO 4mm OCC 0 OCC 0 Z 90 Z 90

Pretreatment Progress 160

N. Nash N. Nash 162

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N. Nash N. Nash 163 164

N. Nash N. Nash 165 166

N. Nash N. Nash 167 168

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N. Nash N. Nash

N. Nash Pretreatment N. Nash Posttreatment N. Nash FMIA 70 FMIA 69 FMA 20 FMA 19 IMPA 90 IMPA 92 SNA 83 SNA 83 SNB 80 SNB 80 ANB 3 ANB 3 AO-BO 4mm AO-BO 0mm OCC 0 OCC 0 Z 90 Z 90

Pretreatment Progress

Posttreatment 172

N. Nash N. Nash

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Is Mixed Dentition Extraction Expedient For the Majority of Crowded Class I Dentitions? N. Nash NO!!!! 176

M. Denman M. Denman 177 178

M. Denman Pretreatment FMIA 77 FMA 21 IMPA 82 SNA 78 SNB 78 ANB 0 AO-BO -4mm OCC 10 Z 79 UL 16mm TC 14mm PFH 43mm M. Denman AFH 60mm 179 INDEX .70 180

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M. Denman M. Denman 181 182

M. Denman M. Denman 183 184

M. Denman Pretreatment M. Denman Recall FMIA 77 FMIA 77 FMA 21 FMA 21 IMPA 82 IMPA 82 SNA 78 SNA 78 SNB 78 SNB 79 ANB 0 ANB -1 AO-BO -4mm AO-BO -4mm OCC 10 OCC 8 Z 79 Z 80 UL 16mm UL 16mm TC 14mm TC 14mm PFH 43mm PFH 47mm M. Denman AFH 60mm AFH 62mm 185 INDEX .70 INDEX .75 186

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M. Denman

Pretreatment Posttreatment 187 M. Denman 188 Recall

M. Denman 189 190

Extraction of Teeth in the Mixed Dentition ─

A Reasonable Option for Selected Patients?

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Two Key Words In My Caveman Practice ─ Less Than 10%!! of the •Reasonable Patients Between the Ages of 8 and 12 Have Mixed •Selected Dentition Extractions

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If It Is Reasonable ─ And If Age 15 the Patient Has the Criteria IT IS A GREAT PATIENT

SERVICE! 195 196

Fifty-Eight Years After Mixed Dentition Extraction

No Other Treatment

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Thank You!

Age 68

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