NON EXTRACTION TREATMENT PROTOCOL
INTRODUCTION
The correction of many malocclusion require space inorder to move
teeth to more ideal location, the orthodontist is often faced with
dilema of how to obtain space required for these correction planning
space is an important aspect of treatment planning
Common instances of space requirement
1) To relieve crowding / impacted teeth
2) To correct proclination
3) To level the curve of spee
4) To intrude teeth
EXTRACTION DECISION MAKING WIGGLEGRAM
Wellington and Afonso JCO 2002
The decision to extract teeth is one of the critical decision in
orthodontic treatment.
The main reasons for extraction are well documented: crowding,
dentoalveolar protrusion, the need for facial profile alteration, and
mild anterioposterior maxillary discrepancies
In borderline cases there can be considerable disagreement.
According to Buchin, a case is borderline when extraction of
permanent teeth is required to reach a stable and functional
occlusion, but when the patient has good facial esthetics that could
be disturbed by extraction.
Wigglegram:
18 factors have been selected from dental, cephalometric, facial and
growth variables
Dental Variables:5 variables
• Dental discrepancy:4-8 mm, 8mm> extraction
• Curve of Spee: 3-6 mm
• Bolton discrepancy: proximal stripping with discrepancy of 4 mm
• Peck and Peck Index: normal 88-95, above 95%-proximal stripping,
less than 88% - extraction
• Irregularity Index: normal-0, mild irregularity-3.5-6.5, greater than 6.5
indicates extraction
Cephalometric variables:7 variables:4 – vertical facial proportional; 3 –
lower incisor position
Relationship of the horizontal planes: according to Sassouni, the
horizontal relationship of the supra-orbital, PP, occlusal, and
mandibular planes reflects the vertical proportionality of the
craniofacial skeleton. Highly divergent planes indicates a skeletal
open bite – extraction, parallel planes indicates – skeletal deep bite –
nonextraction.
FMA: normal values - 20°-30°,
SN-mandibular plane angle: normal- 30°-34°
Jarabak ratio: proposed by Jarabak and Fizzel normal- 61%-69%,
less than 61% - skeletal open bite and more than 69% is skeletal
deep bite.
IMPA: Margolis, 85°-95° is normal greater than 96° indicates for
extraction.
FMIA: 60°-70° is normal, less than 60°indiacates proclination, and
more than 70° indicates retroclined incisors.
METHODS OF GAINING SPACE IN PERMANENT DENTITION
1) Selective/ therapeutic extractions
2) Arch expansion
3) Molar distalization
4) Derotation of posterior teeth
5) Inter-proximal reduction
6) Proclination of anterior teeth in some cases
Types of clinical cases in Orthodontics:
1) Definite extraction cases
2) Definite non-extraction cases
3) Borderline cases
ARCH EXPANSION
Arch expansion was first introduced by Emerson.c.Angell in 1960
The upper arch is well suited for expansion than its lower
counterpart.
Usually done in narrow contracted upper arches with crossbites in the
premolar region.
Important to distinguish between dental and skeletal crossbites
because the treatment approach differs.
Dental crossbite – Slow expansion screws or expansion with the
archwire itself
For skeletal crossbites, splitting the midpalatal suture becomes
mandatory.
Done either by a RME screw in younger patient or by a surgical
procedure in adult patients.
TYPES OF APPLIANCE
Slow expansion
1. Jack screws
2. Coffin spring
3. Quad helix
Rapid expansion
Removable
Fixed
1. Hass type
2. hyrax type
3. Isaacson type
4. Derichsweiler type
HASS TYPE
Bands on the 1st molars
• Wire framework on the lingual of the 1st & 2nd
bicuspids and the 1st molars
• Palate expansion Screw
• Acrylic Palate that rest on the lingual tissue of the
palate
BONDED RME
QUAD HELIX
W ARCH
PROXIMAL STRIPPING
This is usually done whenever the space required for correcting the
malalignment is minimal (3-4 mm).
Can be done in either arch
Can be done manually with abrasive strips or with an airotor
Decision to do interproximal reduction is based on the model analysis
concerning the overall size discrepancy.
It could also be added up with a Bolton analysis.
MOLAR DISTALIZATION
The upper arch is better suited for distalization than the lower; the
reason being the nature of the bone in the mandible
Effects of molar distalization:
1. Proclination of anteriors
2. Opening up of the mandibular plane angle
INDICATIONS
Good soft tissue profile
Borderline cases
Mild to moderate space discrepancy with missing 3 rd molars/2nd
molars not yet erupted
End on molar relationship with mild to moderate space requirement
Cases with less than a full cusp class II molar relationship
Classification
1. Location of appliance
Extra-oral
Intra-oral
2. Position of appliance in mouth
Buccal
Palatal
3. Type of tooth movement
Bodily movement
Tipping movement
4. Compliance needed from patient
Maximum compliance
Minimum or No compliance
5. Type of appliance
Removable
Fixed
6. Arches involved
Intra-arch
Inter-arch
Distalization using Headgears
Very efficient
Reciprocal forces are not transmitted to other teeth
Molar movements depends on direction of force in relation to the
Centre of Res of the molar & magnitude of force
Cervical Headgear
Short face Class II maxillary protrusive cases with low MPA &
Deepbite
Extrusive & distalizing effect
Lower anterior facial height is less
High pull Headgear
Produces intrusive & Posterior direction of pull
Long face class II patients with high MPA
Force through C Res – Intrusion & distal movement of molar
High pull Headgear
Produces intrusive & Posterior direction of pull
Long face class II patients with high MPA
Force through C Res – Intrusion & distal movement of molar
Straight pull headgear
Class II Malocclusion with no vertical problems
Prevent anterior migration of maxillary teeth, translate them
posteriorly
K-Loop molar distalizing appliance Valrun Kalra – JCO 1995
K-loop – forces - .017 x .025 TMA
Nance button – anchorage
8mm long , 1.5 mm wide
Legs- 20 degree bend
Inserted into molar and first premolar tube
VARIOUS APPLIANCES FOR MOLAR DISTALIZATION
Headgears
Wilson Bimetric arch design
Molar distalization with magnets
Use of Super elastic NiTi
Jones Jig
The Pendulum appliance
The K-loop appliance
The distal jet
Using Implants
DEROTATION OF POSTERIORS
The posterior teeth when rotated,occupy a larger space than when they are
normally placed.
Derotation helps in achieving a good occlusion as well as in converting a
borderline case into a non-extraction case, when combined with one of the
earlier methods.
Six Keys To Non Extraction
In recent years there has been an increase in percentage of non-
extraction cases in the average orthodontic practice. The reasons
may be
Mid arch extractions can compromise facial esthetics – concave
profiles – Bishara et al AJO 1995
Patients preference for a broader smile
Expanding the maxillary arch then provides more space for the
dentition, and there is no need for overjet reduction
Patients prefer not to extract the healthy teeth
First key: lee way space
Leeway space – 7mm in the lower and 5mm in the upper becomes
available
To capture this space – fit an lip bumper, lingual arch or an palatal
bar
Dugoni et al (AO – 1995) – has shown that stable results can be
achieved by using leeway space than by extracting premolars
Second key: mesial molar rotation
70% of all malocclusions have mesial molar rotations which are
responsible for a high percentage of class II molar relationships –
Cetlin et al JCO 1983
Rotated 1st molar may occupy 12mm of mesiodistal width, compared
to 10mm for a properly oriented first molar.
Correcting the molar rotations not only increases the available space,
but also changes the archform from a tapered “V” shape to a “U”
shape, providing extra space for overjet reduction
Third key: passive uprighting
Passive uprighting occurs when constrictive forces are removed
4mm increase in arch width can be achieved with lip bumpers or
Frankel appliance – during late mixed dentition (Nevant et al, Osborn
et al, Frankel et al, Hime et al)
Fourth key: active uprighting
After teeth are locked into established malocclusion, an expander
may be used for uprighting.
To avoid relapse – teeth should not be tipped excessively.
Fifth key: distal movement
Distal movement of 1st molars achieved easily before eruption of
second molars
Distalization with headgear along with a removable appliance ACCO
should be worn for continuous force
Sixth key: skeletal modification
Proper use of functional appliances reduces the need for extractions
Alternatively orthognathic surgery that brings the lower jaw forward to
correct the overjet and improve the facial profile is a common non
extraction strategy in most orthodontic practices.
Thank you
