Clinical Case: When would you consider serial extraction? (VIDEO SOLUTION)
January 28, 2013
A 9-year old girl presents to your office for routine examination when you notice that teeth 5.3 and 6.3 have exfoliated prematurely and the 1.4 is erupting very near the 1.2. Your assessment from examination, xrays and models is that she is a young girl in mixed dentition with a hypoplastic maxilla characterized by a shalllow overbite and crowding.
You consider serial extraction. How severe is the crowding? What allows you to make the diagnosis of crowding? What are the indications for serial extraction in this case and are there any contraindications?
From Drs. Austin Chen, Vaughan Orthodontics and Ian Furst, Coronation Dental Specialty Group
Question Video
Answer Video
In my practice a case like this would be going to the orthodontist. For the sake of discussion, my first thought would be to try and use an appliance to hold back posterior teeth and move incisors forward to try and make some space for adult canines. At some point, I suppose it may have to be concluded that some extractions will be needed for proper alignment. When that is, is a good question.
Mark
If your like me, the timing of serial extraction was lost shortly after 4th yr pedo. Austin gives a pretty good summary of which kids it might be indicated for. He lists 4 specific indications in the video.
Austen, in ts case are you only recommending extraction of upper bi’s? Or if you are recommending extraction of lower bis? If you were to extract the lower bis, since she has a shallow overbite and minimal overset, would you still put a lingual arch in or allow the bite to deepen?
And no one mentioned what wonderful crowns and excellent hygiene this child has after having obviously a history of high caries rate in the past. Don’t think this is my patient but kudos to the Pediatric dentist (I can only assume that because we love our stainless steel crowns) and family dentist to bring this child to a state of good oral health so that she can be prepared for orthodontics!
Hi Phu-My, Thanks for the questions! In this case we opted only to extract the upper premolars as she presented with nearly a full-cusp Class II molar occlusion and only mild lower crowding. Had we proceeded with mandibular extractions, I would not have placed a lingual arch to allow the bite to deepen as she presented with an openbite tendency.
You have a great eye for details Phu-My!
Have done many serial ext cases and many looked like they had ortho.Important to have good case selection and some luck. Nearly all could not afford ortho and opted for this treatment. Some were just one arch and some were just one side and some were just one tooth but patient benefited in all. Some were left till patient was older and could get ortho at a later time. Many worked out very well. Experience is a great educator!!
Austin in your opinion could the ectopically erupting 4’s / early loss of the Cs be caught at an earlier time? Is there an indication for a pan film in a child in mixed dentition?
Hi Alex. Thanks for your questions. Since this was a situation of primary crowding where there was an inherent tooth size to jaw size discrepancy (ie. the jaw was too small to accommodate all the teeth), in my opinion little could have been done even if it was caught earlier. In borderline cases, one may opt to attempt maxillary expansion to help increase the jaw size or to consolidate the existing spacing to create more room for erupting dentition, however in this case of severe crowding, this would only provide marginal benefit.
With regards to your question about indication of a pan film of a child in mixed dentition, the American Association of Orthodontists recommends an orthodontic evaluation no later than Age 7. A comprehensive evaluation, which may well include a panoramic radiograph, may detect subtle problems with jaw growth and emerging teeth while some baby teeth are still present. So yes there is good indication for a pan film in mixed dentition.
Austin, if the patient has a class 1 molar relationship do you recommend extraction of the lower bicuspids?