Ortho lecture #2
كاظم النمري.د
………ENJOY
1
…B-reduce # of teeth by extraction
We have seven ways but we are not gonna talk about them all and
: (they are (* = dr talked about it
* space management-1
molar distalisation-2
We here enlarge the arches by moving the molars more distally (we
..(wont talk about it
* serial extraction-3
premolar extraction-4
* first molar extraction-5
lower incisor extraction-6
.7-2nd molar extraction
2
..SPACE MANAGEMENT
3
If crowding is more than the leeway space that means that it's not
enough to correct crowding, and you cant utilize a space for crowding
.when the leeway space is already smaller than the crowding itself
The leeway space is (as you recall) the difference between the MD
width of the 3, 4, 5 in the permanent dentition and the C, D, E in the
deciduous dentition and the leeway space is mostly due to the difference
between the E and the 5 (coz the D is not that bigger from the 4, the C is
…(even smaller than the 3
4
Here we use the term DRIFTODONTICS which means to drift
…(move) teeth
In orthodontics we mean to push teeth into their places but in
driftodontics we give the chance for the teeth to move to the normal
position, and teeth are so nice that if they are given space during
.development of dentition they will move.. or drift
5
.The more logic one is the mesial surface
So by that we are doing inter proximal stripping for the C and then
.the incisors will relieve themselves
??So what to do
Trim the mesial surface of the D.. and this will also give the 4 (1st
..premolar) a chance to erupt
6
Band and loop?? No bcoz this will not change any thing, coz it
prevents 6 from coming forward but doesn’t push the anteriors distally
(and this is what we want), coz due to its touching the mesial tooth to the
extraction site it will prevent them from going distally, and due to
touching the distal tooth to the extraction site , it will prevent it from going
.mesialy
So these are the two ways to manage space.. either extract the E's and
place translingual arch, or slice the mesial surface of the deciduous C
...or\and the D before the eruption of the permanent canine
Now after the extraction of the C , the anteriors will move to occupy
…most of that space
Now (in the upper arch) the second tooth to erupt is the 1st premolar
(4), we want to accelerate its eruption, and this is done by (wait for a while
.after extracting the C) extracting the D
7
??Q: Once we extract the D, what will happen
8
Any way.. there is a complication of the extraction of the C..in the
last lecture I (DR) told you that if I extract a canine on one side there will
??be a midline shift.. and if we extract both C's, what will the incisors do
They will spread (and that is something we want), BUT they will
: collapse or tilt lingually and there will be some results that are
A- increased overjet and overbite
.B-collapse of the lips
At the end of the day, we will have the 4 extracted, if the patient has
a missing 5 then we absolutely don’t do serial extraction for him, and if
we do, we will end up in 2 missing teeth in each quadrant and that is too
.much space
If the canine is very close to eruption (keep in mind that the 4 erupts
before 3 in upper..), and we cant accelerate the eruption of 4 (to erupt
.before the 3) here we don’t do serial extraction
9
When the laterals are still erupting in a crowded position, and the
crowding is severe, we will extract the C's when the roots of the 1st
deciduous molar (D) are half resorped, bcoz if early extraction of the D
(b4 half the root is resorped), this wont accelerate the eruption of the 4 and
instead of that, it will delay the eruption of the 4.. very late extraction of
..the D is not good also
There was an info that the Dr told us, but then he said forget it.. any
way I'll write it to you :: some people think that the presence of the canine
.helps in the transverse growth of the arch, but this is very debatable
BUT if the incisors are rotated.. and you give enough space, they will
return to the line of arch, but they will still rotated.. so we don’t do serial
.extraction
10
Q: when does serial extraction give you a perfect result at the
?end of the day
1st there is no perfect result in that, but you may have a satisfying
reduction of crowding, and if you are lucky enough, you will have perfect
.alignment of teeth
In fact, serial extraction is fading away from the textbooks, its there
as a history , and nowadays pts have dental insurance (that can be
provided by qualified orthodontists without the need to be bothered by
doing serial extraction, knowing that the pt will need a fixed appliance
later on) in most of the countries that adapted the serial extraction
measure, so its debatable, and frequently done by people with low Socio
.Economic Status
11
Another student : teeth may relapse in the fixed orthodontics
Dr: yes that is true.. and this is what we don’t see in serial extraction
..bcoz we extract to get a space and we don’t push teeth
12
?Q: how many molars does he have
you are in your clinic one day (hopefully), a 9 year old kid presented
to you with a badly destroyed lower 6, you say I can treat it by endo and
SSC and later a permanent crown, but I think (dr) its better to do
13
extraction of the 6, and the 7 will have the chance to get the place of the 6,
…and hopefully later on the 3rd molar will erupt in the place of the 7
The problem of the extraction of the 6 is that you might not have a
good contact between the 2nd premolar and the 2nd molar which is the most
difficult thing to judge, but if we have crowding in the buccal segment
particularly in the area of the 6 then we have two advantages of extracting
: the 6
A-relieve crowding
Now , for the 2nd molar to come forward, it shouldn’t have erupted
.yet and its root development shouldn’t exceed 1/2 of it
Bcoz if the 7 erupts and the 6 extracted later, there is no chance for
the 7 to move forward, if > 1/2 of the root of the 7 has been formed, then
.its better for you to do restorative treatment (6) rather than extraction
If there are any missing teeth (2nd premolars), we wont extract the 6's,
and unlike serial extraction if the 3rd molar isn’t there we cant also extract
..the 6's coz you will leave the pt with only one molar
14
.So 2- all teeth should be there including the 3rd molar
After extracting the 6, the 5 will go distally, it will hit the 7 then it
will go up, so distally inclined premolars are not a trouble if the 6 is
.(present (mesial surface of the 6
But if the 6 is extracted, the 5 will go further back to hit the 7 and
..(then go up (more distance travelled
no need for further prostheses, bcoz the 7 will take the place of the -1
..6
15
.less chance of third molar impaction -4
Its in the lower, while in the upper , mesial drifting of the teeth is
much easier and thus space loss is also easier (than the lower).. so the 7 in
.the upper arch will move easier
??Q: How does the space disappear after the 1st molar extraction
If we extract the lower molar only, the upper opposing molar will
supra erupt, the adjacent lower 7 will start to move mesially, but it wont
16
accomplish this bcoz it will be locked in the upper supra erupted 6 (in the
..photo below).. if the opposite happens .. nothing will get locked
If we extract in the lower and we aim for space closure, then we have
.to extract in the upper and this is what we call compensatory extraction
In the upper arch as we said after extraction of the 6, the 7 will start
to move forward and will take the space of the 6, the 4,5 and the anteriors
will never go distally to fill the space (so there will be no midline shift), so
when you extract the upper 6 there is no need to do balanced extraction or
..compensatory
But if in the lower arch, if you extract the 6, there will be a shift in
.the midline, so balanced and compensatory extractions are needed
So extraction of four 6's (in case of the lower), this means four
.uncertainties about the contact between the 5 and the 7
17
Q: do we accept a small shift in the midline for the sake of two
???????sound permanent teeth
In the lower is better, bcoz the space is very difficult to close, and
even if closed, this would be due to distal movement and not full
.occupation of the space
In the upper it’s a risk, if we are going to extract the upper 6 in case
of severe crowding, the space will close completely just by the eruption of
…the 7
If you have crowding in the buccal segment, you can extract bcoz
..there is a chance to relieve that crowding
18
Thank you
19