Asymmetric Extractions Used in the Treatment of Patients With Asymmetries

Joe RebeUato
Patients with dentoalveolar asymmetries can present some of the most biomechanically challenging situations to the orthodontist. One creative approach for managing dental asymmetries is to extract a combination of teeth that will simplify intra-arch and interarch mechanics. Often this will also reduce the dependency on patient compliance for elastic wear and may even shorten treatment time. Atypical extraction patterns can also be beneficial in the presurgical orthodontic preparation of orthognathic surgery patients. Multiple diagnostic scenarios are discussed, and various treatment plans involving asymmetric extraction patterns are reviewed. (Semin Orthod 1998;4:180-188.) Copyright 1998 by W.B. Saunders Company

h e c o n t r i b u t i o n of c o o r d i n a t e d facial, maxillary, a n d m a n d i b u l a r m i d l i n e s to a successful o r t h o d o n t i c o u t c o m e a n d g o o d facial b a l a n c e is undisp u t e d . A l t h o u g h m i n o r asymmetries are e n c o m p a s s e d within t h e r a n g e o f clinical acceptability, large skeletal a n d d e n t a l deviations f r o m t h e facial m i d l i n e can p r o f o u n d l y d e t r a c t f r o m a p l e a s i n g aesthetic result. 1-3 I n a d d i t i o n , significant m i d l i n e discrepancies c a n pose a b i o m e c h a n i c a l c h a l l e n g e to t h e o r t h o d o n t i s t . Most investigators w h o have written o n the subject o f m i d l i n e c o r r e c t i o n have d e s c r i b e d strategies u s i n g asymmetric i n t e r a r c h t r e a t m e n t m e c h a n i c s to o b t a i n a c o r r e c t i o n of this type o f m a l o c c l u s i o n J -1 However, a t t e m p t i n g to achieve m i d l i n e c o o r d i n a t i o n with asymm e t r i c elastic wear, s u c h as a c o m b i n a t i o n of Class II a n d Class III elastics o r a n t e r i o r d i a g o n a l elastics, may be f r a u g h t with u n d e s i r a b l e side effects if skeletal b a l a n c e already exists. I n a d d i t i o n , t h e force vectors c r e a t e d by t h e elastics i m p a r t a m o m e n t to t h e m a n d i b l e , ie, a t e n d e n c y for r o t a t i o n t h a t m a y lead to a t r a n s i e n t a l t e r a t i o n in m a n d i b u l a r position. Unless a stable skeletal r e l a t i o n s h i p is o b t a i n e d b e f o r e removal of o r t h o d o n t i c appliances, relapse may o c c u r as t h e m a n d i b l e shifts back to a m o r e physiological posture. D i s c o n t i n u a t i o n o f s u c h asyminetric, i n t e r a r c h elastics for a trial period before d e b a n d i n g may help to confirm stability of m a n d i b u l a r position. It is crucial to d e t e r m i n e w h e t h e r t h e factors t h a t cause t h e a s y m m e t r y are skeletal o r d e n t o a l v e o l a r in

From the Mayo Foundation, Rochest~ MN. Address correspondence toJoe Rebellato, DDS, Mayo Clinic, 200 First St SW, Rochest~ MN55905. Copy*Jght 1998 by W.B. Saunders Company 1073-8746/98/0403-000758. 00/0

origin o r a c o m b i n a t i o n o f b o t h . Results f r o m a study by Miller et al n i n d i c a t e t h a t t h e maxillary m i d l i n e is situated in t h e exact m i d d l e o f the m o u t h (using the p h i l t r u m as a guide) in a p p r o x i m a t e l y 70% o f individuals, b u t t h a t t h e maxillary a n d m a n d i b u l a r m i d l i n e s c o i n c i d e in only o n e f o u r t h o f t h e p o p u l a t i o n . Several studies have a t t e m p t e d to c o m p a r e t h e relative posit i o n i n g of b o t h skeletal a n d d e n t a l structures in p a t i e n t s with Class I as o p p o s e d to Class I P 2 or Class II subdivision I~ malocclusions. In a well-conceived study, Rose et al 1~ f o u n d t h a t o t h e r t h a n t h e m a n d i b u l a r m o l a r b e i n g l o c a t e d m o r e posteriorly o n t h e Class II side, Class II subdivision m a l o c c l u s i o n s s h o w e d n o o t h e r u n u s u a l asymmetries in the m a n d i b l e . A l t h o u g h t h e study m e a s u r e d only m a n d i b u l a r s t r u c t u r e s f r o m s u b m e n t a l v e r t e x r a d i o g r a p h s a n d c o u l d n o t test any maxillary l a n d m a r k s , t h e findings were n o n e t h e l e s s statistically significant for t h e m a n d i b u l a r m o l a r position c o n t r i b u t i n g highly to the malocclusion. T h e f i n d i n g o f this d e n t o a l v e o l a r a s y m m e t r y was n o t so obvious f r o m a n t e r o p o s t e r i o r or lateral c e p h a l o m e t r i c radiographs. It is also i m p e r a t i v e to a s c e r t a i n w h e t h e r a d e n t a l m i d l i n e deviation is d u e to a b u c c a l s e g m e n t asymmetry, or w h e t h e r it is primarily d u e to u n e v e n c r o w d i n g in t h e arches.14 Before m a k i n g a definitive diagnosis, a m e n t a l c o r r e c t i o n of m i d l i n e position, while f a c t o r i n g in t h e d i s t r i b u t i o n o f crowding, s h o u l d b e m a d e . I n essence, a n i m a g i n a r y situation is c o n c e i v e d t h a t a t t e m p t s to estimate w h e r e t h e m i d l i n e m i g h t reposition if all t h e t e e t h in t h e a r c h were a l i g n e d w i t h o u t extractions. This m i g h t relocate t h e d e n t a l m i d l i n e closer to or c o i n c i d e n t with the facial midline, b u t it m i g h t also relocate it f u r t h e r f r o m t h e facial midline. This w o u l d e i t h e r t e n d to r e d u c e or increase the

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severity of the asymmetry that is clinically observed in the patient. Mandibular shifts f r o m centric relation to maxim u m intercuspation must also be d o c u m e n t e d in the p r e t r e a t m e n t records. D e p r o g r a m m i n g of the masticatory musculature with an occlusal splint may be indicated in certain instances to obtain an accurate r e c o r d i n g of centric relation before making irreversible t r e a t m e n t decisions. As in the previous scenario, the severity o f the midline discrepancy may be increased or decreased, d e p e n d i n g on how the mandible repositions. Therefore, the treatment-planning process of patients with either skeletal or dental asymmetries or both needs very close scrutiny to discern the area or areas responsible for the deviation and to be able to direct t r e a t m e n t modalities accordingly. A n u m b e r of different diagnostic scenarios will be discussed, all of which assume skeletal symmetry in the patient. T h e t r e a t m e n t of true skeletal asymmetries is m o r e thoroughly e x p l o r e d in the last article in this issue titled "Surgical Correction of Patients With Asymmetries," by Dr H a r r y Legan.

Mandibular Dental Midline Deviation With Skeletal Symmetry

Class I1 subdivision malocclusions have b e e n r e p o r t e d to account for 50% of all Class II malocclusions, and it appears that the majority of these have distally positioned m a n d i b u l a r molars on the Class II side. 13 This also implies that the m a n d i b u l a r canine on that side is also positioned distally on the mandible. If such a patient presented with the maxillary dental midline coincident with the facial midline, and extractions were an acceptable option for the patient, a threep r e m o l a r extraction plan may be the t r e a t m e n t of choice (Fig 1). T h e extraction of a m a n d i b u l a r p r e m o l a r on the Class I side relocates the canine in a m o r e distal position to match the contralateral canine. T h e extraction of two u p p e r premolars would maintain the maxillary midline symmetry to the facial midline. A significant benefit of such an extraction pattern would be to minimize, if n o t obviate, the d e p e n d e n c e on intermaxillary elastics to c o m p l e t e treatment. Dealing with buccal s e g m e n t asymmetries with an asymmetric extraction pattern often results in a biomechanically simplified t r e a t m e n t plan. If the m o l a r on the Class II side is in an end-on relationship, Class I closure mechanics can be used in all three extraction buccal segments, with minimal, if any, titration of space closure with intermaxillary elastics (Fig 2). However, if the same m o l a r is in a full-step Class II relationship, additional measures may be n e e d e d to limit u p p e r m o l a r a n c h o r a g e loss on that

side. For example, the p l a c e m e n t of a passive transpalatal arch could increase molar anchorage. For additional anchorage, the transpalatal arch can also be activated to apply a distally directed force to the molar. However, it must be r e m e m b e r e d that this activation o f the transpalatal arch will also result in a mesial-out m o m e n t and a reciprocal, mesially directed force at the contralateral m o l a r that may or may n o t be desirable.15,16 However, if the plan were to extract a fourth premolar, namely a m a n d i b u l a r p r e m o l a r on the Class II side, all the extraction spaces on the Class II side would have to be closed by complete retraction of the maxiUary anterior teeth and c o m p l e t e protraction of the m a n d i b u l a r s e g m e n t distal to the extraction site (Fig 3). It would, therefore, be beneficial to choose a differential extraction pattern on the Class II side, such as the removal of a maxillary first p r e m o l a r and m a n d i b u l a r second p r e m o l a r to h e l p lose lower molar anchorage. M t h o u g h the extraction of a m a n d i b u l a r p r e m o l a r on the Class 1I side may m i n i m i z e the flaring of incisors f r o m Class II elastics by providing arch space for the m a n d i b u l a r m o l a r to advance during maxillary canine retraction, it also creates a t r e a t m e n t plan that is m o r e d e p e n d e n t on patient compliance. Mandibular dental midline deviations can also result f r o m a unilateral Class III malocclusion. T h e anterior teeth may be in an edge-to-edge or even crossbite relationship. T h e option of o n e p r e m o l a r extraction on the Class III side would allow for primarily Class I closure mechanics, and minimize interarch elastics (Fig 4). If the molar is in a full-step Class Ill relationship, a lingual arch that is either passive or unilaterally activated can be used to maximize m o l a r a n c h o r a g e on that side. 15,16 A drawback to leaving buccal segments in a Class III molar relationship is that it often results in u n o p p o s e d maxillary second molars. If a m a n d i b u l a r third m o l a r is present on the Class III side, it should be retained for intercuspation with the u p p e r second m o l a r if it is in a g o o d position or is expected to e r u p t into a g o o d position. If the third m o l a r has yet to erupt, a maxillary r e t e n t i o n appliance should be designed to prevent s u p r a e r u p t i o n of the u p p e r second molar until the third m o l a r has e r u p t e d into occlusion.

Maxillary Dental Midline Deviation With Skeletal Symmetry

Deviation of the maxillary dental midline from the facial midline in Class II subdivision malocclusions can be caused by multiple factors, including premature loss of a primary maxillary second molar, leading to mesial drift of the p e r m a n e n t first molar on the Class II side. In a growing patient, many approaches may be used to achieve acceptable molar relationship

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Figure 1. A patient with a Class II subdivision right malocclusion with maxillary midline position assessed as acceptable. Both upper first premolars and a lower left first premolar were extracted as part of the treatment plan (A-C). The initial end-on molar relationship on tile Class II side allowed for mostly intra-arch closure mechanics, with a right-sided Class II molar finish. The left-sided premolar extractions helped to maintain maxillary midline position and Class I molar relationship (D-F).

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A )~ ~

activated transpalatal arch could be used to control molar anchorage, and space closure could be accomplished primarily through Class I mechanics with minimal patient compliance. If extractions in the mandibular arch are necessary because of excessive crowding, and if a Bolton's tooth size discrepancy exists, the extraction of a lower incisor or lower incisor proximal reduction may greatly simplify the biomechanical complexity of the case (Fig 6). The extraction of four premolars in such a case i ~ requires the use Of differential interarch mechanics' which will have a tendency to affect final mandibular and, ultimately, maxillary dental midline position. The increased dependence on patient compliance with elastic wear may also make a successful outcome less predictable.

Maxillary and Mandibular Dental Midline Deviation With Skeletal Symmetry

True deviations of both maxillary and mandibular midlines to one side of the facial midline are uncommon and must be clearly identified from similar clinical appearances brought about by asymmetric arch crowding. If uneven crowding exists, a mental correction of midline position based on the irregular distribution of the crowding should be performed. If after this adjustment both midlines are still visualized as being off to one side, the extraction of ipsilateral

"

nonextraction correction of the Class II buccal segment less predictable. If such a patient has a mandibular arch that does not necessitate extractions, the removal of a maxillary premolar on the Class II side would greatly facilitate correction of the canine to a Class I relationship (Fig 5). A passive or slightly

Figure 3. Class II subdivision malocclusions treated with four premolar extractions can require significant unilateral Class II elastic wear. Complete one-sided space closure is often required in full-step Class II buccalsegments.

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Figure 4. A patient with a unilateral Class III buccal segment; acceptable facial symmetry, profile, and maxillary dental midline position; and supraerupted maxillary second molar (A-C). Extraction of the lower right second premolar resulted in a posttreatment Class III molar relationship. The third molars were impacted and had to be extracted, leaving the upper right second molar unopposed (D-F).

upper and lower premolars may be the appropriate plan to follow. The decision to extract first or second premolars or a combination of these is dependent upon the amount of midline correction that is desired, and any differential molar anchorage requirement as dictated by the original buccal segment relationship. If the maxillary and mandibular midlines are both

off from the facial rnidline, but in this instance on opposite sides from each other, it is likely the result of asymmetric arch crowding. However, if the buccal segments reflect this asymmetry, the appropriate plan in this situation may be the extraction of an upper premolar on the Class II side and a mandibular premolar on the Class III side. As previously mentioned, the drawback to a Class III molar relationship

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Figure 5. A patient with a Class II subdivision left malocclusion with minimal intra-arch crowding and maxillary midline position assessed to be deviated to the right of the facial midline. The upper left first premolar was extracted as part of the treatment plan (A-C). A transpalatal arch was used to supplement maxillary molar anchorage resulting in solely Class I space closure, obviating any interarch elastics (D-F).

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Figure 6. A patient with a Class II subdivision right malocclusion with severe arch crowding and maxillary midline position j u d g e d to be to the left of the facial midline. The u p p e r right first p r e m o l a r and a lower central incisor were extracted (A, B). T h e maxillary dental midline at the e n d of t r e a t m e n t was j u d g e d to be slightly to the right of the facial midline, although i m p r o v e d f r o m its initial position. An anterior Bolton's discrepancy h e l p e d in achieving near ideal overbite and overjet (C, D).

is the u n o p p o s e d u p p e r second m o l a r on that side, unless the lower third m o l a r is present or is anticipated to e r u p t into g o o d occlusion.

Asymmetric Extractions and Orthognathic Surgery

Problems can arise if o r t h o g n a t h i c surgery is p l a n n e d for patients who have asymmetric buccal segments but have symmetric skeletal bases that are c o i n c i d e n t with the facial midline. Unless some type of asymmetric extraction pattern or mechanics is e x e c u t e d before surgery, a facial asymmetry will result as a function of

the asymmetric a d v a n c e m e n t or setback of the maxilla or mandible, or a c o m b i n a t i o n of both. Because one of the goals of orthognathic surgery is the attainment of a Class I canine relationship, it is preferable for the canines to be as symmetric as possible prior to surgery in o r d e r to facilitate an optimal a d v a n c e m e n t or setback of either jaw. This minimizes the rotational c o m p o n e n t b r o u g h t about by asymmetric skeletal m o v e m e n t s that could create posterior transverse discrepancies that did n o t exist before surgery. In bilateral sagittal split osteotomy surgery, a straighter a d v a n c e m e n t or setback preserves facial

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Figure 7. A patient with m a n d i b u l a r retrognathia, acceptable facial symmetry and maxillary dental midline position, and a "double-step" Class II molar relationship of the left buccal segment. Two u p p e r premolars and a lower right p r e m o l a r were extracted to obtain a presurgical occlusion with symmetric Class II canine relationships (A-D).

symmetry and minimizes the a m o u n t of "kick o u t " of the proximal s e g m e n t caused by i n t e r f e r e n c e with the ramal p o r t i o n of the distal s e g m e n t (Fig 7). In quadrangular Le Fort osteotomy surgery, m i n i m i z i n g rotation of the maxilla during a d v a n c e m e n t is a crucial and essential c o m p o n e n t of a successful facial outcome.m,2

References
1. Breakspear EK. Some aspects of the retraction of upper incisors by appliances. Thirty-eighth Congress, European Orthodontic Society. J Eur Orthod Soc 1963:342 (abstr). 2. Hulsey CM. An esthetic evaluation of lip-teeth relationships present in the smile. AnlJ Orthod 1970;57:132-144. 3. Dierkes JM. The beauty of the face: An orthodontic perspective. J Am Dent Assoc 1987 (special issue):89E95E. 4. Angle EH. Malocclusion of the Teeth. Philadelphia, PA, SS White, 1907. 5. Strang R, Thompson W. A Textbook of Orthodontia. Philadelphia, PA, Lea & Febiger, 1958. 6. Gianelly AA, Paul IA. A procedure for midline correction. AmJ Orthod 1970;58:964-267. 7. Lewis D. The deviated midline. AmJ Orthod 1976;70:601616.

Conclusion
A f u n d a m e n t a l objective of o r t h o d o n t i c therapy is the i m p r o v e m e n t of facial and dentoalveolar aesthetics. F r o m a social standpoint, facial attractiveness may be d e t e r m i n e d m o r e from a frontal than from a lateral view. A l t h o u g h a myriad of factors contribute to facial aesthetics, symmetry may be the quintessential ingredient.

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8. Begg PR, Kesling P. Begg Orthodontic Theory and Technique (ed 3). Philadelphia, PA, Saunders, 1977. 9. Proffit W. Contemporary Orthodontics. St Louis, MO, Mosby, 1986. 10. Alexander RG. The Alexander Discipline. Glendora, CA, Ormco Corporation, 1986. 11. Miller EL, Bodden WR, Jamison HC. A study of the relationship of the dental midline to the facial median line. J Prosth Dent 1979;41:65%660. 12. Alavi DG, BeGole EA, Schneider BJ. Facial and dental arch asymmetries in Class II subdivision malocclusion. AmJ Orthod Dentofac Orthop 1988;93:38-46. 13. Rose JM, Sadowsky C, BeGole EA, et al. Mandibular skeletal and dental asymmetry in Class II subdivision malocclusions. AmJ Orthod Dentofac Orthop 1994;105: 489-495. 14. Howe RP, McNamaraJA, O'Connor KA. An examination

15. 16. 17.

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19. 20.

of dental crowding and its relationship to tooth size and arch dimension. AmJ Orthod 1983;83:363-373. Burstone CJ. Precision lingual arches--Active applications.J Clin Orthod 1989;23:101-109. Rebellato J. Two-couple orthodontic appliance systems: Transpalatal arches. Semin Orthod 1995;1:44-54. Haack DC, Weinstein S. The mechanics of centric and eccentric cervical traction. Am J Orthod 1958;44:346357. Noble PM, Waters NE. Investigation into the behavior of symmetrically and asymmetrically activated face-bows. AmJ Orthod Dentofac Orthop 1992;101:303-341. Keller EE, Sather AH. Intraoral quadrangular Le Fort II osteotomy.J Oral Maxillofac Surg 1987;45:223-232. Keller EE, Sather AH. Quadrangular Le Fort I osteotomy: Surgical technique and review of 54 patients. J Oral Maxillofac Surg 1990;48:2-11.