Extraction and non extraction decision of treatment

1. 1 Extraction and none extraction Extraction and none extraction D Decision of treatment ecision of treatment Prepared by: Prepared by: Dr Mohammed Alruby Dr Mohammed Alruby E Extraction an xtraction and non d non- -extraction extraction decision of treatment decision of treatment Dr Dr. . Mohammed Alruby Mohammed Alruby

2. 2 = One of the most difficult decision in orthodontic treatment is whether to extract or nor, particularly in border line cases. Clinician attitude, concerning this decision have differed significantly = some clinician started to advocate extraction of permanent teeth in some patients such as, (Pierce 1859, Angle 1887, Farrar 1888, Case 1869) = in 1907, Angle recommended non-extraction (expansion) treatment and start extraction philosophy by Calvin Case and his associates = in the middle of 1940 Tweed publication greatly support the view of case and recommend extraction of permanent teeth in certain cases. Since that time, the extraction become very popular treatment strategy. = Brodie commented “soon the air is filled with bicuspids” by 1960 a more conservative philosophy has been developed recommending non-extraction approaches for three reasons: 1-Perfect treatment results with non-extraction approach using functional appliances and orthopedic forces. 2-Developed of direct bonding technique, that eliminate the need for an additional space to be occupied with band materials 3-Development of risk management philosophy as a result of legal implication of extraction ** Nowadays extraction is considered as an alternative treatment plane and not a crime, however a great caution should be exercised before deciding irreversible treatment plane ** the difficulty usually faces the orthodontist during management of border line cases. In clear cut extraction or no-extraction cases the decision is much easier and the results are more guaranteed. ** the difficulty in taking such a decision in border line cases may originate from many intermingling factors, so that, the clinician has to depend on two ways to make his mind up: 1-Systematic thinking based upon the use of all available diagnostic data 2-The artistic clinical judgement, by which the clinician can evaluate and predict the outgoing appearance of the patient ** the border line case is the case in which both treatment modalities (extraction and no) can be conducted but, actually, only one of them will has superior result than other. In such cases, the space deficiency may be 3 –4mm or 4 –6mm Factors that affect the decision of treatment plane toward extraction or non-extraction 1-Cephalometric analysis: In dental border line cases the deviation from the normal range is not too much, the angular and linear measurements are at the low or high norm of its means value, because if measurement is beyond norm, this may change the case from border line to clear cut case. a-Dental measurements: I- Anterior posterior direction: -Inclination of upper and / or lower incisors: When the upper and / or lower incisors are retroclined, there will be a chance to gain space through Proclination of these teeth, thus eliminating the needs for extraction. Many cephalometric analyses are designed to measure incisors inclination: U1 : L1 ------ 127 degree U1: FH ------112 E Extraction an xtraction and non d non- -extraction extraction decision of treatment decision of treatment Dr Dr. . Mohammed Alruby Mohammed Alruby

3. 3 U1 : Sn-------104 U1: pp -------70 L1: Mp ------95 L1: FH ------65 L1: N-Pog -----2mm -1st molar position: Several analyses were, made to assess 1st molar position: Upper: 6 to NA --------- 27 -+3 ----- Steiner 6 to Pt point------ age of patient -+3 ---- Ricketts 6 to key ridge 6 to temporal curve of Sassoni 6 long axis to SN------------- Sassoni 6 long axis to pp ------- Sassoni 6 long axis to occ p ------- Sassoni 6 long axis to Mp ------ proffit Lower: 6 to NB 23-+3 ------------ Stainer 6 to Xi point 40-+2.8 6 to Mp ------ Bell, Proffit When analyses reveals that, 1st molar shifted mesially, there is possibility for non-extraction treatment approach by distalization treatment II- Vertical dento-alveolar height: Vertical dento-alveolar height of anterior and posterior teeth can be assessed cephalometrically, by measuring the distance from the occlusal plane to maxillary plane for upper and to mandibular plane for lower teeth U1 to pp distance; -------- 33-+3 males or 30 -+3 females U6 to pp distance: ---------28-+3 males or 25-+3 females L1 to Mp ------------------49-+3 males or 24-+3 females L6 to Mp distance -----------38-+3 males or 33-+ females When analysis reveals discrepancies in these measurements this indicate that intrusion or extrusion is required As a general rule: intrusion require additional space and may tip the balance toward extraction, the reverse is true for extrusion III- Transverse dental relationship: The buccolingual inclination of posterior teeth can often assessed from PA cephalogram. When diagnosis reveal palatal or lingual tipping of posterior teeth, decrease the inter-molar width, then non-extraction approach by buccal expansion of the arch should be considered Normal inter-molar width -----54.5mm---- Ricketts Normal inter-canine width ------23.9mm ----Ricketts. b-Skeletal measurements: I- Anteroposterior relationship: ANB angle and wits Appraisal: When these measurements reveal a mild skeletal discrepancy (mild class II or III) then extraction is required to camouflage the underlying skeletal discrepancy. E Extraction an xtraction and non d non- -extraction extraction decision of treatment decision of treatment Dr Dr. . Mohammed Alruby Mohammed Alruby

4. 4 Cases with moderate skeletal dysplasia are border line between orthodontic camouflage and orthognathic surgery. II- Vertical relationship: Increase LAFH tip the balance toward extraction, because of the possibility to reduce the bite through mesialization of buccal teeth, while patients with decreased LAFH can be treated with distalization tend to open the bite Increase FMP angle allow extraction rather than distalization III- Transverse relationship: Assessed through PA cephalogram, when analysis demonstrate transverse skeletal, and the patient is still growing, there will be a chance to gain space and correct the buccal cross bite through the rapid maxillary expansion rather than extraction. c-Profile analysis: Orthodontist have long been recognized that extraction is associated with changes in soft tissue profile, these changes may be favorable in some patients, however it may produce dished in profile in other cases. Young and Smith shown that non-extraction approach has less effect on facial profile then extraction Most of profile changes comes from the changes in lip position following extraction or Proclination of incisors, so we need careful estimation of: -Lip position -Size of nose -Nasolabial angle -H angle -E line -Lower lip to H line 2-Case analysis: a-Tooth size arch length discrepancy: -Mild to moderate crowding 3 -4 mm in which the space can gain through: expansion, distalization, Proclination of incisors and enamel re-approximation -Peck and Peck ratio: it is the ratio between the mesiodistal width (MD) to the faciolingual (FL)width of incisors = MD width / FL width X 100: Normal ratio for Egyptian = 88.8-+0.5, if it increases above 88.8 so ----- re-approximation is indicated to adjust the index -How’s analysis: basal arch width at premolar area / tooth material anterior to 2nd molar X 100 Normal ratio 37% ----- 44% If this percentage less than 37% --------------- extraction If this percentage more than 44% -------------- non-extraction -Bolton tooth ratio analysis: Over all ratio: sum of MD mandibular 12 teeth / sum of MD maxillary 12 teeth X 100 = 91.3% Anterior ratio: sum of MD of mand. 6 anterior / sum of MD max. 6 anterior X 100 = 77.2% When analysis reveal discrepancy in MD width between upper and lower teeth, then re- approximation may be necessary to adjust the ratio -Kesling diagnostic set up: E Extraction an xtraction and non d non- -extraction extraction decision of treatment decision of treatment Dr Dr. . Mohammed Alruby Mohammed Alruby

5. 5 Give more accurate estimation of the need for extraction and which tooth should better remove, when correcting the axial inclination of incisors alone or together with some Proclination, or stripping can result in an accepted relationship, then extraction is not required N: B: Kesling diagnostic set up: The teeth are cut from the cast at the level of A and B points then repositioned according to Tweed formula FMIA: 65 degrees --- this method determines the following: 1-If the case is indicated for extraction or not and aid in choosing the teeth to be extracted 2-The amount of space created by extraction and the tooth movement necessarily to close the space 3-Help to determine the type of anchorage as minimum, moderate and maximum. b-Anteroposterior relationship: -Overjet: normal overjet or slightly increase with retroclination of lower incisors and or spacing of upper incisors ------------- non-extraction -Molar relationship: normal class I molar relationship or slightly deviated (cusp to cusp) which can be corrected with mesialization of lower 1st molar or distalization of U6 --------- - non-extraction c-Vertical relationship: Normal curve of spee, or slightly increase which can be corrected by extrusion of posterior teeth alone --------------- non-extraction d-Transverse relationship: posterior cross bite due to palatal tipping of buccal teeth------ non-extraction approach by expansion 3-Miscellenous factors: a-Age of patient: Extraction decision in young orthodontic pt should be carefully undertaken, because continuous growth of the jaw may change the pattern obtained by extraction ------- spacing and difficulty in space closure Careful growth prediction should be considered, taking into account the amount of inter-canine width increase not expected after 9 years In addition, Frankel, Macnamara, Andreson among others have been reported the possibility of excellent treatment of Class II and class III molar relationship at an early age with non-extraction approach using functional appliances and / or orthopedics forces b-Chief complaint: When patient is interesting is his facial profile, and complaining the protruding teeth ------- extraction c-Psychology: desire and pt cooperation: Some pt refuse extraction, uncooperative pt ------- non-extraction d-Length and coast of treatment: If this consideration to be taken non-extraction preferred in border line cases e-Third molars: Most of cases has impacted third molar, can extract it and make distalization to create space f-Past medical history: E Extraction an xtraction and non d non- -extraction extraction decision of treatment decision of treatment Dr Dr. . Mohammed Alruby Mohammed Alruby

6. 6 The presence of complicating factors such as endocrinal disease and blood disease ------ non- extraction g-Past dental history: The presence of complicating factors such as: hypercementosis, fusion, dilacerations, high caries index, poor oral hygiene, relation to sinuses ------- non-extraction treatment h-Relapse: Must be take into consideration as the effect of type of treatment on the environment around the tooth and its ability to relapse N: B: When all factors do not prefer one method over the other, the conservative approach should take first (non) then evaluate the case is necessary. In such situation the pt and parents must be informed about the probability of changing the treatment plane to extraction due to unprotected factor, in such instance the lower incisor extraction may be the treatment of choice E Extraction an xtraction and non d non- -extraction extraction decision of treatment decision of treatment Dr Dr. . Mohammed Alruby Mohammed Alruby