American Journal of ORTHODONTICS

Volunze 60, Nuwder 6, December, 1971

ORIGINAL ARTICLES

Serial extraction: A continuous diagpzostic

and decisional process
1. M. Graber, D.D.S., M.S.D., Ph.D.*
Chicago, Ill.

T here is nothing new about the use of progressive guided extraction

procedures to expedite the eruption of teeth. Kjellgren, Hotz, Mayne, Dewel, and
others have written extensively on the subject.l- For a long time teeth have been
removed to allow others to come into place and assume more esthetically desirable
positions. More recently, the oral surgeon has been confronted with almost
routine requests from the orthodontist for the removal of teeth. Which teeth
should be removed, and when? How many teeth should be removed? Is it always
the first premolarsl What is the effect on the later eruption of the second and
third molars? On overbite? What is the justification for tooth removal as an
integral part of orthodontic procedures? There are a number of questions that
can be asked and should be asked by the oral surgeon before he blindly follows
the dictates of the orthodontist.
With our increasing emphmis on teamwork, it is imperative that all mem-
bers of the team know what each service is trying to do/l The patients certainly
will benefit from a cross-fertilization of ideas, and each specialty will have a
greater appreciation of the problems, the possibilities, and the potentials of total
service. Serial extraction is an excellent example of a multidiscipline approach
that exemplifies the best to be gained from teamwork. It is the purpose of this
discussion to give some of the background and to delineate the reasons for tooth
removal. A series of cases is shown to demonstrate the autonomous improvement
that may be achieved, and a section is devoted to some of the problems.
lh4 do of expansion
It was not until the early 1940s that expansion of the dental arches as a
means of eliminating irregularities was pretty well recognized by orthodonti&

*Chairman, Department of Orthodontics, University of Chicago.

541
542 Graber Am. J. Orthod.
December 1971

as a two-edged Sword. In Class I malocclusions, it was possible to eliminate the

irwwlarities, but teeth were moved into abnormal stress positions and into
muscle forces. Thus, in a challenge which essentially involved harmonizing teeth
with basal bone, with normal muscle and jaw relationships, an imbalance was
established. Such measures provided a temporary correction at best.2
In Class II malocclusions, expansion was n?ld still is a valid treatment
objective, for there is concomitant change in muscle function and jaw relation-
ship with successful Class II therapy. Indeed, restoration of normal function
is a prime treatment objective. In Class I malocclusions, however, where there
is a lack of harmony between the amount of tooth material and available basal
bone and where the patient already has a normal muscle activity, the movement
of teeth off of basal bone into functional forces is not likely to produce a stable
orthodontic result. The retainers splint the teeth, holding them outward in a
sufficiently large arc to allow the alignment of individual units, but the muscle
forces are constantly exerting greater than normal forces from the outside. As
soon as the retainers are removed, or the wearing of them is reduced sufficiently
to allow the muscles to play a dominant role, there is a relapse and resultant
irregularity that may not be much different from the original problem. Con-
siderable research in electromyography and telemetry, using sophisticated
electronic equipment, has validated the clinicians concern about expansion
procedures in orthodontics in Class I malocclusions.35
Growth and development

Not all clinicians are aware of the physiologic basis for the stable tooth
positions in orthodontics, and many have not studied the research just mentioned,
which demonstrates the dynamic balance of the three tissue systems-teeth,
neuromuscular, and osseous.
There has been a recent renaissance of the expansionist doctrines of tooth
movement, based on techniques that were developed in the nineteenth century
and are still used in some parts of the world today-the use of removable ap-
pliances with cast or wrought-wire extensions to exert pressures on teeth and
thus cause them to move. Of course, teeth may be moved either lingually or
labially, mesially or distally, with applied pressures. Claims have been made
that growth is being stimulated or we are taking advantage of growth and
development. Like ham and eggs, growth and development seem inseparable
and certainly provide more than semantic euphony for the orthodontist.
In Class XI, Division 1 malocclusions, where there is a basal malrelationship
of the maxilla and mandible, with the teeth merely reflecting this abnormality,
and where there is a disha.rmony and malfunction in the muscle system and
appropriate proprioceptive and neurologic feedback response, it is apparent that
there must be aberrations in the third element, or the tooth system. Growth and
development guidance, harmonizing the three systems, is imperative. However,
in Class I malocclusions, where there is already a normal anteroposterior rela-
tionship of maxilla to mandible, where there is already harmonious muscle
activity, and where the problem is merely within the tooth system, with its
disproportionate amount of tooth material, the only growth that may be
Volzltns 60 Se&l extraction 543
Number 6

INTERCANINE ARCH GROWTH

Fig. 1. Graph showing early completion of mandibular intercanine growth in both

boys and girls. In the maxilla, however, a significant sex-linked difference is seen, as
maxillary intercanine dimension serves as a safety valve for puberty-linked horizontal
mandibular growth increments. The later pubertal growth spurt in boys 112 to 18 years1
accounts for the continuing intercanine increase in the maxillary arch. [Adopted from
Moorrees, C. F. A., Fanning, E. A., and Gron, A. M.: Augle Orthod. 33: 44-59, 1963.1

harnessed is within the alveolar arches and adjacent muscle system. It is ilt
Class I cases that serial extraction finds its most successful application. How
much of a factor is growth in the alveolar arches! When and where does this
happen! Is the timing sex-linked%
Moorrees and others have conducted longitudinal studies on arch-length in-
crease and increments of growth.22r 36 Fig. 1 shows that by the end of the ninth
year in girls and the tenth year in boys the mandibular intercanine arch width
dimension is essentially complete. In the maxilla, there is little further maxillary
arch width increase in girls after the age of 12 years. The bar graph shows that
in boys the maxillary intercanine dimension may continue to increase until the
age of 18 years. This difference in the maxilla is due to the fact that the pubertal
growth spurt in girls appears from lOl/, to 12 years of age, while in boys it is
from 12 to 18 years.3G The maxillary intercanine arch width increase serves as
a safety valve for the dominant horizontal basal mandibular growth spurt,s.
This terminal horizontal incremental mandibular growth is particularly a malt
sex-linked characteristic and may be demonstrated routinely with cephalometric
radiographs (Fig. 2). Nevertheless, it would be inconsistent with the present
knowledge of growth and development to expect any appliances to increase
mandibular intercanine arch width after 10 to 11 years of age. The maxillary
increase is a recognition of the need for adjustment for basal mandibular grovrth
and must be left for this purpose.31l 35,36
Thus, if there is a Class I malocclusion with generalized crowding, the
clinician would be most unwise to resort to expansion of the maxillary and
544 Graber Am. J.
Decsmber
Orthod.
1971

Care: 8. If. age: 9 10 11 12 14 16

SNQA
0;; 785 76.5 760 76.5 765
AB Dill. 6.5 7.0 5.5 4.5
NaS-Gc,G~ 42.0 490 44.0 41.0 40.0 4E
Ul-NOS 1 00.0 84.0 8Q.O 89.5 96.0 97.0
Ll-GoGn 89.0 84.0 860 90.5 92.5 94.0
Ul-NaPogtmm) 14.0 8.0 7.5 60 7.5 8.0

- QYRS
--- 1oras
._-..-.. _. , , y*s
--- 12 YRS
- 14YRS
--- 16 YRS

Fig. 2. Prepubertal mandibular growth direction is primarily vertical. Note abrupt

horizontal swing with onset of puberty. Maxillary canine adjustment occurs as a result
of the basal mandibular forward positioning. Mandibular intercanine integrity is actually
stressed at this time, periling any attempt at intercanine distance increase by Nature or
by appliances. If the overbite is excessive, the integrity of the lower anterior segment
is further endangered.

mandibular arches with fixed or removable appliances, hoping for growth to

bail him out. The creation of an abnormal muscle activity, with increased
muscle tissue system pressures on the expanded dental arches and the production
of inharmonious relationship of the tooth system to the basal bone system (in
other words, the creation of two abnormal tissue systems from what was
originally a normal relationship, merely to satisfy the demands of alignment of
teeth) are hardly calculated to enhance the longevity of the stomatognathic
system. This is what the orthodontist now calls an iatrogenic malocclusion, and
the damaging effects are clearly evident to the periodontist at a later date.

Arch-length measurements
As Mayne31 has pointed out so well, the incisor liability may be measured
from the cast and long-cone radiographs, and the magnitude of the deficiency
(usually 6 to 7 mm., even when there is no crowding) has to be made up by an
average of 3 to 4 mm. of intercanine arch growth plus the contribution of 2 to
3 mm. of interdental (developmental) spacing and 1 to 2 mm. of increased arch
length through more anterior positioning of the permanent incisors as they
erupt. The space situation is even more critical in the lower dentition, because
Volume 60 Xerial extraction 545
Number 6

Fig. 3. Leeway space as described by Nance. This greater width of deciduous teeth,
as compared to permanent successors, is usually less than 1 mm. in the maxillary
arch. In the mandibular arch, it averages between 1.5 and 2 mm. This allows mesial
drift of mandibular first molars from the flush terminal plane relationship illustrated
into the correct intercuspal permanent dentition relationship. The horizontal mandibular
growth increments, illustrated in Fig. 2, may also play a part in establishing the final
positions. Preventing the normal mesial drift of the mandibular molars to gain arch length
may perpetuate the flush terminal plane relationship (Class II tendency), and this could
cause other problems.

this is the contained arch and the transient developmental deep bite may well
prevent the attainment of optimum intercanine growth and labial positioning
of the lower incisors.28 It should be emphasized that the vertical dimension can
influence the anteroposterior relationships of teeth and jaws.
What about using the so-called leeway space in the buccal segments if the
anterior teeth are crowded? How about using the extra width of that large
mandibular second deciduous molar? With the work of Nance, we know that the
combined width of the mandibular deciduous canines, deciduous first molar,
and deciduous second molar is, on the average, 1.7 mm. greater than that of the
permanent successors, the canine and first and second premolars (Fig. 3) .T, *
Nance showed that, in the maxillary arch, the deciduous canine and first and
second molars were approximately 1 mm. greater in width than the permanent
successors. This amounts to about 3.5 mm. in the mandible and approximately
2 mm. in the maxilla. Can this space be used to make up for arch-Iength
deficiencies ?
 Am. J. Orthd.
December 1971

FLUSH
TERMINAL
PLANE
6 S ERUPTING

DISTAL
STEP
S ERUPTING

Fig. 4. Moyers has shown that at least 50 per cent of normal developing dentitions
have a flush terminal plane relationship that corrects itself only with the loss of
deciduous molars at the end of the mixed-dentition period. (See Fig. 3.) This Class II
tendency may become full fledged, with a distal step, where there is a morphogenetic
Class II pattern or an excessively deep overbite and resultant functional retrusion.*2

First of all, the leeway space varies considerably, depending on tooth size
and the proportionate relationship of deciduous and permanent teeth. More than
this, however, there is what MoyerP calls the flush terminal plane relationship,
with the first permanent molars in an end-to-end cuspal contact (Fig. 4). The
orthodontist would call this a Class II tendency. This is a normal, transient
developmental phenomenon, and it is seen in a large percentage of cases. With
exchange of the deciduous for the permanent teeth, there is a mesial drift of the
mandibular first molar, taking up the leeway space and allowing the mesio-
 Se&d extraction 547

buccal cusp of the maxillary first molar to lock into the mesio-buccal groove of
the mandibular first permanent molar. The leeway space, then, is usually a
reserved bit of arch length to allow for the adjustment of maxillary and man-
dibular dental arches during the critical tooth-exchange period.? Use of this
space, holding back the molars to gain arch length anteriorly, may very well take
a Class II tendency problem and turn it into a full Class II, Division 1 malocclu-
sion. Prevention of the settling-in of the cusps and grooves may product
premature contacts, enhancing bruxism and functional problems. To satisfy
the demands of arch length in this instance would be to obvert the developmental
and physiologic phenomena that would normally occur.
Hence, the orthodontist must recognize the limitations of expansion tech-
niques in the treatment of Class I malocclusion, and he must know that to ignore
the interrelationship of the three tissue systems-the tooth system, the neuro-
muscular system, and the bone system-is to invite ultimate relapse. The problem,
succinctly, is a five-room house on a four-room foundation. In Class I, the
neuromuscular and bone systems are already harmonious in their interrelation-
ships, and it is the job of the orthodontist to bring the third system (the tooth
system) into balance by judicious, guided extraction procedures. As Dewel*3
says : By this procedure, serial extraction avoids one form of orthodontic
negligence ; teeth in marked discrepancy cases are not first required to assume
positions of extreme irregularity and then subjected to extensive orthodontic
movement with extraction to establish acceptable occlusal relations. They are,
instead, permitted to take these positions in the first place.

Selection of teeth for extraction

After the importance of harmonizing the amount of tooth material with the
available bony support is recognized, the next obvious question is: What teeth
should be extracted? Since most Class I malocclusion involve irregularities of the
canines and incisors, with space deficiency appearing most critical in this area,
the layman may ask: Why not take out a tooth here ? It is not hard for the
dentist to answer this question. The importance, from an esthetic and functional
standpoint, of maintaining bilateral symmetry rules out the choice in all but a
few exceptional cases (for example, cases involving unilateral congenital absenrc,
anomalous teeth, cleft lip and palate, and severe caries).
Historically, as extraction became more prevalent in orthodontics, the first
premolars became the usual teeth of choice for removal. However, the mere
removal of four teeth was no open sesame to success. The orthodontist soon
found that, unless he controlled the remaining teeth effectively with efficient
multiband appliances, he could close most spaces but might end up with only
part of the original malocclusion corrected. He might even face additional
characteristics of malocclusion produced by tipping of teeth to poor stress-
reception positions or by his inept handling of the situation.
Orthodontic therapy in extraction cases requires a degree of orthodontic
skill and training well beyond the level of general practice.ll The need for control
of individual teeth is paramount. An iatrogenic malocclusion with deep overbite,
spaces, improper contacts, teeth in abnormal axial inclination, and functional
548 Graber Am. J. Orthod.
December 1971

aberrations could well be worse than the untreated original crowding charac-
teristics of the patient.12* 1 23 Thus, the pervading theme in the following pages
is that serial extraction is a valuable adjunct in the treatment of Class I maloc-
elusion but it is an orthodontic decision and requires the knowledge, know-how,
and clinical experience of the specialist who ultimately must complete the therapy
in ahnost all cases. In the best interest of the patient, all serial extraction cases
should be handled with the ultimate responsibility vested in the hands of the
orthodontist. TOO much irresponsible tooth movement has been seen in pedodontic
circles, without the benefit of expertese in changing diagnostic decisions and
appliance manipulation.
As more and more orthodontists prescribe removal of more teeth during
orthodontic therapy, they find that the first premolar is not always the best tooth
to be sacrificed. Sometimes it is the second premolar, or the second premolars in
one arch and the first premolars in the other arch.3s Caries may necessitate the
removal of a first permanent molar, or the choice may be maxillary second molars
only. The decision depends on an exhaustive study of all available diagnostic
criteria and a thorough understanding of orthodontic principles and mechano-
therapy. The competent orthodontist knows full well that, at best, diagnosis is a
tentative decision and re-evaluation of the patients status at each examination
with a periodic radiographic survey is essential. There is no cookbook in guided
or progressive extraction procedures. While the dentist in general practice cannot
be expected to know all these things, he should at least be aware of what the
orthodontist is doing and know some of the general reasons behind his decisions.
The removal of certain teeth to establish a stable orthodontic result in
harmony with the investing tissues has given rise to an additional question:
When should the teeth of choice be removed? Taking a clue from Nature, which
exfoliates the deciduous canines early in arch-length-deficiency problems, is
it advisable to remove the deciduous canines and deciduous molars early to
allow the permanent teeth to align themselves better as they erupt az4Will this
prevent the permanent incisors and canines from assuming positions of extreme
irregularity which require extensive orthodontic therapy and extraction of
premolars to achieve the desired result! Instead of waiting for all the permanent
teeth to erupt into a full-blown malocclusion, why not intercept in the early
mixed dentition by relieving the crowding to give Nature a chance to adapt with
adequate space? The answer is a conditional yes. However, before embarking
on this robbing Peter to pay Paul procedure, the orthodontist must ask himself
a number of questions (Fig. 5).
First, is the discrepancy between tooth size and available supporting bone
such that the teeth will not be able to find sufficient room for the proper alignment
on their own?lsl 25 It must be remembered that the teeth have achieved their
ultimate size when they erupt but the dental arches have not. The parents
occlusion or the hereditary pattern may provide information of value at this
point. Detailed study and precise measurements of deciduous teeth and their
permanent successors must be made before any decision can be reached.
Second, are both the patient sand parents aware that serial extraction is a
continuing program of orthodontic guidance over a period of 4 or 5 years?
VoZume 60 Serial extraction 549
Number 6

I I TH DECISION

1OTH DECISION

9TH DECISION

ETH DECISION

7Tl-l DECISION

6TH DECISION

STH DECISION

4TH DECISION NEW RECORDS

3RD DECISION

2ND DECISION

1ST DECISION SERIAL EXTRACTION YES OR NO ?

INCIPIENT MALOCClUSlON
Hg. 5. Which road shall it be? After a diagnostic study of an incipient malocclusion,
a yes or no decision is made, tentatively, for a program of guided extraction. If the
decision is yes, then this is just the first of at least a dozen decisions that will have
to be made over a period of 2 to 4 years. Unless the dentist is prepared to travel this
road and make the decisions, on the basis of adequate diagnostic criteria, he should
not start the trip in the first place. [After Mayne, W. R.: in Graber, T. M.: Current Ortho-
dontic Concepts and Techniques, Philadelphia, 1969, W. B. Saunders*2 Company.]

Unless it is made clear to the parents that the child must be observed at periodic
intervals over a prolonged time, that teeth will have to be removed during this
period as directed by the orthodontist, and that the orthodontic guidance will
likely culminate in a period of actual mechanotherapy, nothing should be started.
A poorly guSed serial extraction program may be worse than nothing at all,
making the appliance problems more difficult or making complete correction
impossible.2s
Third, the orthodontist must also be fully aware that serial extra&ion is
not a pat one-two-three procedure. He may have to alter his tentative program
550 Graber Am. J. O&hod.
December 1971

YEARS
mm 2 4 6 8 IO 12 14 16 18
r III1 ( I I I I I I I I I II

T I2 Pm,,
MAXILLA

--.

28

26

28

26

24

I%.LI2 114 1 611 811 IO11 I2I I4 I 16I I

YEA;:
Fig. 6. As Moorrees shows, total arch length, or clinical arch length from the first per-
manent molar to its counterpart on the opposite side, maxilla and mandible, male
and female, does not increase; it decreases. Tying in with Figs. 3 and 4, mesial drift
of the mandibular first molar is greater, utilizing the larger second deciduous molar
space to eliminate the flush terminal plane relationship. (Solid line = male; dotted =
female.)

one or more times during the period of observation, depending on the degree of
self-adjustment during the period, on other sequelae of malocclusion, on the
speed and order of the eruption of permanent teeth, and on similar factors. Be-
cause of developmental changes that could not be predicted, what appears as a
serial extraction case at 7 or 8 years of age may not seem so at 10 or lOl/,. The
orthodontist must be prepared to reverse his decision on the basis of current
diagnostic records. He may have to institute mechanotherapy earlier than
planned, or he may have to place appliances more than once if he is to achieve
the total correction possible from an intelligently guided orthodontic manage-
ment.
If the general practitioner wishes to undertake a serial extraction program,
he must ask himself if he has the skill and training required to cope with the
problems of overbite, axial inclination, space closure, torque, rotations, paral-
leling, and the complexities of the appliance necessary to achieve the best
possible result for the patient. This is a rhetorical question, for very few general
practitioners or pedodontists have the training and experience necessary.31
Volume 60 Serial extructiow~ 551
Number 6

So-called orthodontic appliances, fabricated by self-styled orthodontic labora-

tories, are most certainly not the answer, Yet, with proper orthodontic guidance
and the recognition that appliance therapy must be expected and is required
for almost all patients, serial extraction will become a valuable adjunct in prac-
tice, greatly reducing the amount of appliance therapy needed for the correction
of Class I malocclusions. It will lessen the length of time that appliances need
to be worn and minimize untoward sequelae, such as root resorption, decalcifica-
tion, and soft-tissue proliferation, which so often accompany protracted periods
of appliance therapy. Possibly, too, financial invest,ment for the patient may 1~
decreased.
Indications for serial extraction

When an orthodontist sees a child 5 or 6 years of age with all the deciduous
teeth present in a slightly crowded state or with no spaces between them, he can
predict, with a fair degree of certainty, that there will not be enough space in
the jaws to accommodate all the permanent teeth in their proper alignment.,
As Nance, Moorrees, Dewel, and others have pointed out, after the eruption of the
first permanent molars at 6 years of age, there is probably no increase in the
distance from the mesial aspect of the first molar on one side around the arch
to the mesial aspect of the first molar on the opposite side (Fig. 6) .7f lo: ?2 If there
is any change, it may be an actual reduction of the molar-to-molar arch length,
as the leeway space is lost through the mesial migration of the first permanent
molars during the tooth-exchange process and correction of the flush t,erminal
plane relationship33 (Fig, 4).
There are other cardinal clues that point to the possibility of serial extrac-
tion (Figs. 7 and 8). The following is a list of possible clinical clues for serial
extraction, occurring singly or in combination :
1. Premature loss.
2. Arch-length deficiency and tooth size discrepancies.
3. Lingual eruption of lateral incisors.
4. Unilateral deciduous canine loss and shift to the same side.
5. Mesial eruption of canines over lateral incisors.
6. lXesia1 drift of buccal segments.
7. Abnormal eruption direction and eruption sequence.
8. Flaring.
9. &topic eruption.
10. Abnormal resorption.
11. Ankylosis.
12. Labial stripping, or gingival recession, usually of lower incisor.
If gingival recession and alveolar destruction are present on the labial aspect
of one or several mandibular incisors in a child 8 to 9 years of age, complete
records should be taken to make a positive diagnosis and to outline a plan of
management. If a child of this age has had premature loss of one or both
mandibular deciduous canines, this may well have been due to pressure against
the deciduous canine roots by the crowns of the erupting permanent lateral
incisors. This condition is a significant hint to a wise clinician. Very often only
552 Graber Am. J. Orthod.
December 1971

Fig. 7. Clues for serial extraction. A, Maxillary canine, mesial, erupting labial to lateral
incisor; B, arch-length deficiency with lateral incisor erupting lingually [mandibular ca-
nines will erupt mesially); C, mesial drift of buccal segments and arch-length deficiency;
D, arch-length deficiency and premature loss of lower right deciduous canine, with
shifting of incisors to that side; E, mesial drift, arch-length deficiency, canine mesial
over lateral incisor; F, deciduous canine being exfoliated spontaneously as a result of
crowding.

one mandibular deciduous canine is lost. As soon as one is exfoliated, the incisors
shift over into the space created, relieving the pressure on the remaining canine.
A cheek of the midline of the mandibular arch shows this quickly. Prompt
removal of the remaining deciduous canines may be indicated (Figs. 7 and 8).
Clues also are seen in the posterior segments. Rotated and tipped permanent
molars in either arch are usually a sign of mesial drift of the buccal teeth,
particularly the first molars. Sometimes the teeth on both sides of the edentulous
Fig. 8. Clues for possible serial extraction are encountered on the routine periapical
x-ray film. Crowding, rotations, arch-length deficiency, abnormal resorption, lingual posi-
tion of lateral incisors, and canine crowns in proximity with lateral incisor roots are
illustrated here.

areas tend to tip into the space. An orthodontic consultation becomes necessary,
for the uprighting and tipping of these teeth distal to their normal positions may
take the case out of the serial extraction category and make more extensive
mechanotherapy necessary. Such a decision must be based on a thorough diag-
nostic discipline.
If the mixed-dentition analysis, arch-length measurements, and mesiodistal
measurements of unerupted teeth substantiate the clinical impression of space
inadequacy, the parent should be informed of the need for a long-range program
of interceptive orthodontic guidance, with premature removal of deciduous teeth
in sequence at times determined by the patients own development. This is to
allow improved alignment of the erupting permanent teeth by temporarily in-
creasing the available space. Ultimately, permanent teeth usually have to be
removed to eliminate the inherent arch-length deficiency, and orthodontic ap-
pliances will be needed to establish the correct occlusion.
554 Grnber Am. J. Orthod.
Decemhe~ 1971

Fig. 9. Seven-year-old girl with tongue-thrust habit and arch-length deficiency. Lack
of room for maxillary lateral incisors may mean their eruption into lingual malposition
and subsequent mesial eruption of maxillary canines. The discerning dentist would
immediately suspect a potential serial extraction problem when he saw the abnormal
resorption on mandibular deciduous canines, and he would refer the patient for an
orthodontic consultation, even though the patient is only 7 years old.

Dependence on maxillomandibular relationship

It must be emphasized that any planned program of serial extraction is

dependent on the maxillomandibular relationship. If it is normal, as evidenced
by the correct interdigitation of the buccal segments (Class I malocclusion),
chances of success are relatively good, with proper guidance and patient coopera-
tion. If the maxillomandibular relationship is abnormal (Class II and Class III
malocclusions), a serial extraction program must be approached with great cau-
tion, with considerable reservation and with the expectancy that the basal
malrelationship must be adjusted by appliances prior to completion of the
permanent dentition. DewelI writes : Severe Class II discrepancy irregularities
are treated primarily with Class II mechanics, with serial extraction more or less
as an accessory to mechanical therapy. Only the orthodontist can make this
decision.31 The classic serial extraction technique must apply largely to Class I
malocclusions.
Mayne15 points out that serial extraction should be limited largely to those
cases that have good faces: . . . those that present harmony and balance of two
tissue systems, bone and muscle, and varying degrees of disharmony in the third,
tooth size. In these cases, the apical bases are located directly under one another
and the incisor teeth are upright to these bases. They are reasonably well over the
ridge and so related to facial anatomy as to produce the most complimentary
facial esthetics.31

Technique of serial extraction

At the outset, it should be said that there is no one single technique for
serial extraction. A tentative diagnostic decision is the best that can and
Vozume 60 Seriul extraction 555
Numbw 6

Fig. 10. Three patients under pedodontic care but not referred for orthodontic cons Jlta-
tion. The concern was parental, not pedodontic. In the top laminagraph, space IT rain-
taint :rs have been placed despite abnormal resorption, premature loss, crowding, and
rota1 .ions-all clues for possible serial extraction. Despite ectopic eruption of maxi llary
first molars and arch-length deficiency (center), space maintainers were placed. An
arch. -length determination was not done-but should have been. In the bottom v iew,
mult iple clues of ectopic eruption, premature loss, abnormal resorption, unilateral loss and
shift , tipping, rotations, etc. were not sufficient to make the pedodontist request an
orthc ldontic consultation.
556 Graber Am. J. Orthod.
December 19il

Fig. 11. Molar-to-molar arch length may be measured by adapting soft brass separat-
ing wire around the arch as illustrated. Then individual teeth are measured with Boley
gauge on cast and on long-cone radiographs to determine magnitude of discrepancy.

should be made. Serial extraction is a long-range guidance program, and it

may be necessary to re-evaluate and change tentative decisions several times.
Although it is desirable to see a potential serial extraction case while all the
deciduous teeth are still present and to make long-range plans at that time, all
too frequently the patient is 7 or 8 years of age, or even older, before the ortho-
dontist sees him (Figs. 7 and 8). At this time, the maxillary and mandibular
central incisors are usually erupted, but there is inadequate space in the an-
terior segments to allow the normal eruption and positioning of the lateral
incisors. In some instances, the mandibular lateral incisors have already
erupted but are badly malposed, usually lingually. The maxillary lateral in-
cisors may have erupted already, but they usually are lingually positioned and
rotated. If they have not erupted, they may be palpated and located radio-
graphically to the lingual side, in imminent danger of erupting into lingual
cross-bite. Careful digital examination will disclose that the mandibular canines
may also be palpated low in the vestibular fornix, somewhat labial and medial
to where they would normally be expected. There is often a slight diastema
between the maxillary central incisors. Even if this space were closed, there
would not be adequate room for the lateral incisors to assume their place in the
dental arch. A laminagraphic radiographic examination is likely to reveal that
all permanent teeth are present but with totally inadequate spaee in the dental
arches to receive them (Figs. 9 and 10).
Diagnostic c&.&p&e. Complete diagnostic records should be made and
studied. This means study models, undistorted periapical radiographs, panoramic
radiographs, and cephalometric radiographs. 2o The orthodontist uses calipers or
a fine-line divider and measures the combined width of the teeth present in each
segment. The circumferential measurement is made on the plaster cast from
the mesial aspect of the first molar on one side to the mesial aspect of the first
molar on the opposite side, and this measurement is recorded (Fig. 11). We
have already mentioned the fact that the arch length from the mesial aspect
of the molar on one side to the mesial aspect of the molar on the opposite side
Volume 60 Serial extraction 557
Number 6

does not increase after these teeth have erupted, that it actually decreases with
the elimination of the flush terminal plane relationship.33 Thus, it becomes a
simple matter of mathematics to add the combined width of the permanent
teeth as taken off the long-cone intraoral radiographs and to compare this
figure with the available arch length. It is not uncommon to find as much as
a 1 cm. deficiency in either the maxillary or the mandibular arch. To gain
sufficient arch length at this time, the orthodontist may turn to expansion to
create sufficient space for the eruption of lateral incisors, but we know his
dubious chances of success if he sits back and waits for growth and develop-
ment. 35 If he has learned his lessons in oral physiology well, he knows that he
cannot disturb the balance of teeth and bone with that of the muscle system
Any victory would be very temporary, indeed. Thus, to provide a stable and
healthy occlusion, he must turn to guided tooth removal.
Three stages in serial extraction therapy. Having established, by careful
diagnostic study, that there is a significant deficiency, he can embark on his
planned program of guided extraction. This is usually done in three stages.Zl 3l lo
Each stage accomplishes a specific purpose.
1. REMOVAL OF DECIDUOUS CANINES. With exfoliation or removal of deciduous
canines, the immediate purpose is to permit the eruption and optimal alignment
of the lateral incisors. Improvement in the position of the central incisors may
reasonably be expected. Prevention of the eruption of the maxillary lateral
incisors in lingual cross-bite or the mandibular incisors in lingual malposition
is a primary consideration, but this improvement is gained at the expense of
space for the permanent canines. Vitally important is the fact that correct
lateral incisor position prevents the mesial migration of the canines into severe
malpositions that will require concerted mechanotherapy later.
In the maxillary arch, the first premolars erupt uniformly ahead of the
canines. In the mandibular arch, it is statistically less predictable. Sometimes
the orthodontist will try to maintain the mandibular deciduous canines some-
what longer in the hope that he can retard the eruption of the permanent
canines, while the first premolars take advantage of the edentulous area created
by premature removal of the mandibular first deciduous molars. It is desired
by most orthodontists embarking on a serial extraction procedure that th.e
first premolars erupt as soon as possible and ahead of the canines so that the
premolars may be removed, if necessary. This frequently does not happen (Fig.
12). As the experienced clinician knows, there is little evidence that the erup-
tion sequence can be changed, anyway. The too early removal of mandibular
deciduous first molars may very well delay the eruption of the first premolars,
as a dense layer of bone fills in over them following removal of the deciduous
tooth. The question of deciduous canine versus deciduous first molar removal is
largely academic, since Nature usually eliminates the deciduous canines auto-
nomously and early in the frank serial extraction case, often before the patient
is even seen by the orthodontist.
It is important to expedite the normal eruption of the maxillary lateral
incisors. Belated eruption and lingual malposition of these teeth permit the
maxillary canines to migrate mesially and labially into the space that Nature
558 Graber Am. J. Ovthod.
December 1971

Fig. 12. In the top panoramic view, the maxillary first premolars are clearly ahead of the
canines, but the canine is ahead on the lower left and it is about even on the lower
right. In the bottom view, the sequence is as the orthodontist wishes; all four first
premolars are erupting ahead of the canines.

has reserved for the lateral incisors. These high cuspids as the orthodontist
often calls them, make lingual cross-bite of the maxillary lateral incisors more
certain, make orthodontic therapy more difficult, and practically ensure that
the first premolars will have to be removed ultimately, Remember, not all
properly managed serial extraction cases inevitably require the sacrifice of
permanent teeth.
Generally speaking, if Nature has not already spontaneously exfoliated the
deciduous canines or has exfoliated only one or two of them, these teeth are
removed between the ages of 8 and 9 years in patients with an average develop-
mental pattern.
2. REMOVAL OF THE FIRST DECIDUOUS MOLARS. By this procedure, the ortho-
dontist hopes to accelerate eruption of the first premolars ahead of the canines,
if at all possible. This is particularly touch and go in the mandibular arch,
where the normal sequence so often is for the canine to erupt ahead of the first
premolar. The maneuver is seldom successful in the lower arch, as has been
 Serial extraction 559

indicated already. In Class I malocclusions cspccially, the first premolar may bc

partially impacted between the permanent canine and the still present second
deciduous molar. Hence, the dentist may vary the first procedure of removing
all four deciduous canines, as outlined above, and remove t,he first deciduous
molars in the lower arch to tip the eruption scales in the direction of the first
premolar. Usually, however, he has no choice, since Nature has taken the
matter into her own hands with the premature autonomous shedding of the
deciduous canines. The need for another decision at this point emphasizes the
strong reliance on a thorough understanding of the problem, a considered
study of the patients diagnostic records, clinical experience in similar cases,
and the ability to assist with effective mechanotherapy at the proper time.
There are times when the orthodontist, in removing first deciduous molars,
must consider the possibility of enucleating the unerupted first premolars
(usually in the lower arch) to obtain the optimal benefits of the serial extrac-
tion procedure. This is a most hazardous step and obviously requires keen
diagnostic acumen. Yet, in the properly chosen case, the autonomous adjust-
ment and marked improvement in alignment following this step can be most
gratifying to both the patient and the orthodontist (Fig. 13). Where the
canines have erupted prior to the first premolars in the mandibular arch, the
convex mesial coronal portion of the second deciduous molar may interfere with
first-premolar eruption. In such cases, it is necessary to remove the second
deciduous molars. No firm rule can be developed here, and each case is judged
on its merits with proper diagnostic criteria.
Generally speaking, the first deciduous molars are removed approximately
12 months after the deciduous canines. Thus, first deciduous molars would be
removed between the ages of 9 and 10 years in the average developmental
pattern. It would vary from child to child and might sometimes be done earlier
in the mandible than in the maxilla to enhance early eruption of the first
premolars. I6 Timing is really not so critical for removal of the first deciduous
molars, and there are those who might prefer to remove the remaining decidu-
ous canines and first deciduous molars at the same time, somewhere between
the ages of 81, and 10 years. No obvious deleterious sequelae need be expected.
3. REMOVAL OF THE ERUPTING FIRST PREMOLARS. Before this is done, all diag-
nostic criteria must again be evaluated. The status of the developing third
molars must be determined. It can be embarrassing to remove four first prc-
molars, only to find that the third molars are congenitally missing and there
would have been enough space without premolar removal. If the diagnostic
study confirms the inherent arch-length deficiency, the purpose of this step is
to permit the canine to drop distally into the space created by the extraction.
If the procedure has been carried out correctly, and if the timing has been
right, it is a most rewarding experience, after removal of the first premolar%
to see the bulging canine eminences move distally on their own into the pre-
molar extraction sites (Fig. 14). Clinical experience indicates that this hap-
pens more frequently in the maxillary t,han in the mandibular arch. The reason
is the eruption sequence which so often permits the maxillary canine to enter
the oral cavity ahead of the lower first premolar. It is here that the timely
560 Graber Am. J. Orthod.
December 1971

Fig. 13. Severe Class I malocclusion with multiple clues for serial extraction kc topic
erupi .ion , drift, premature loss, abnormal resorption, unilateral loss and shift to that
side, flar *ing, etc.). Deciduous teeth have been removed in center view, but there i: jCt log
iam in the canine-premolar area. The bottom view was taken shortly after enu clew
of al I fc Iur premolars. In the three right-hand views, eruption is preceding, with ma irked
imprc 3vel nent. The middle view shows a partially impacted lower second molar on I the
right sid e; it was surgically uprighted. The bottom view shows completed self-ad)1 Jstn nent.
Volume 60 Serial extraction 561
Number 6

Fig. 13 Contd. For legend, see opposite page.

remov al of the unerupted mandibular first premolar may prevent the abnc Irma1
mesial eruption of the mandibular canine, which would increase the appl ianctl
challel nge later.
As indicated previously, sometimes it becomes necessary to remove the man-
dibula ,r second deciduous molars to permit the first premolars to erupt. T his is
a rnorl e conservative step, and it is usually preferable to enucleation, but it in-
crease s the likelihood that a holding arch may be needed to prevent undu e loss
of spa ,ce and excessive mesial drift of the first permanent molar (Fig. 1 5). A
562 Graber Am. J. Orthod.
December 1971

Fig. 14. A series of panoramic radiographs showing the autonomous alignment of te !eth
and distal uprighting of canines as space is created in the first premolar area.

series of decisions must be made throughout the period of serial ren toval of
teeth. This is why observation appointments at 3-month intervals are ad.visal de.
There is considerable variability in the eruption of the individual fimt Fbre-
molar, and it is often necessary to remove these teeth one or two at a time ! as
they erupt. Close observation and teamwork between the oral surgeon and the
orthodontist are particularly important at this time. If a premolar is just be-
neath the surface and appears to be held up by a mucosal barrier, 1:he oral
Volume GO Serial extractio?a 563
Number 6

Fig. 15. Second deciduous molars may interfere with eruption of first and second
premolars and need to be removed if they are preventing optimum adjustment. Holding
arches are seldom necessary.

surgeon may expedite the serial extraction procedure by incising the tissue and
removing the unerupted premolar. Generally speaking, if the decision has
definitely been made that it is necessary to remove the first premolars, the
sooner this is done the better the self-adjustment. It serves no purpose to
wait for full eruption of the premolar teeth. From the psychologic point of
view, the fewer surgical experiences, the better.

Variations in serial extraction procedure

Since there are a number of variables that contribute to the decision on

what to remove, and when, in serial extraction, it is not possible to develop hard
and fast rules that apply to all cases. In most instances, the serial extraction pro-
cedures are instituted when the patient is about 8 years of age. There is an in-
terval of about 6 to 12 months between steps, as dictated by clinical and radio-
graphic evidence of growth and development, sequence of eruption, and self-
adjustment initiated by the serial extraction procedure.
Not all changes are favorable. Careful, continuous observation is necessary.
There is often an increased inclination of the teeth on either side of the first
premolar extraction site. As Dempster, Adams, and Duddles3* showed in their
study of axial inclination, the long axes of the teeth converge in the maxillary
arch. The compensating curve and the occlusal surfaces of the mandibular arch
form a concave arc, so that the long axes in the mandibular buccal segments
diverge, Thus, there is automatic paralleling of the roots with removal of the
first premolar in the maxillary arch. On the contrary, remova of the man-
dibular first premolar permits the tipping together of the crowns, accentuating
the V or ditch, as it is called in some orthodontic quarters. Seldom does
564 Graba A~nk. J. Orthod.
December 1971

the distance between the apex of the mandibular canine and the apex of the
mandibular second premolar decrease on its own. Uprighting requires fixed
banded appliances.
The bite tends to close at least temporarily during the extraction super-
vision period in most instances, particularly in patients with a Class II tend-
ency. A. Martin Schwarz37 showed that there are three periods of physiologic
raising of the bite, with eruption of the permanent first molar, with the erup-
tion of the permanent second molar and the third molar. This does not happen
all the time, but ample evidence exists to show that, even in serial extraction
cases, there is an autonomous reduction of the overbite with the eruption of the
second and third molars (Fig. 19). This, plus the horizontal growth increments
of the mandible in the terminal phases of development, should improve the
overbite. However, there is no harm in placing an acrylic bite plate in the
mixed dentition. It certainly may help and can do little harm. Preventing over-
closure, stimulating eruption of posterior segments, and eliminating functional
retrusion are worthwhile objectives. In addition, as DewelI points out, if
anchorage is at all a problem in the maxillary arch (this would be especially
true in Class II cases), a removable palatal appliance is valuable in retracting
the canines before the placement of fixed appliances to complete the arch
consolidation.
Sometimes there is a further reduction in arch length during the period
of guidance. The lower incisors, while aligning themselves, may also become
more upright (lingually inclined), which increases the overbite tendency. In
our experience, however, mandibular lingual or maxillary holding arches are
required only in extreme arch-length deficiency cases. In the lower arch, par-
ticularly, holding arches may interfere with optimum adjustment and prevent
closure of the space in the extraction site. Continuous observation of the OC-
clusal relationship of the first molars is advisable because of the occasional
forward rotation of the maxillary first molars, with the mesiobuccal cusp turn-
ing lingually. To prevent this tendency and the creation of a Class II relation-
ship, a maxillary holding arch may be advisable in some cases.28 These problems
constitute a minority of the cases, but they point up the need for continuing
guidance by the orthodontic specialist.
There are times when it is advisable to remove the second premolars instead
of the first premolars. 3s Such a decision may mean the removal of second pre-
molars in one arch and first premolars in another. Canine position, arch length
needed, restorative status of premolar segments, tooth shape, and amount of
overbite and overjet are just some of the factors that influence such a deci-
sion. If there is an open-bite tendency, sometimes the removal of second pre-
molars in the mandibular arch will be preferable because this reduces the
tendency to relapsing open-bite and lingually inclined incisors that are seen
occasionally with removal of lower first premolars. Where there is congenital
absence of mandibular second premolars, the first premolars may drift distally
into the space if the second deciduous molars are removed on time (Fig. 16).
Class II, Division 1 and Division 2 malocclusions with arch-length deficiency
characteristics pose different problems. Serial extraction is still a valuable
 Serial extraction 565

Fig. 16. Congenital absence of mandibular second premolars in serial extraction ca se.
Note distal drift of mandibular first premolars when second deciduous molars have be en
removed. First premolars were removed in maxillary arch.

treatment adjunct but must be closely coordinated with several periods of

mechanotherapy (Figs. 17 and 18). Basal discrepancy and overbite constani ;l y
militate against the achievement of optimal self-adjustment so often seen in
Class I cases where serial extraction has also been employed. Careful study of
all available diagnostic records must precede any decision on tooth sacrifi w
and full diagnostic records should be obtained at least at yearly interva .IS.
566 Graber

Fig. 17. Class II, Division 1 malocclusion complicated by arch-length deficiency. Extra-
oral force against maxillary first molars was used in conjunction with serial extraction.
Favorable growth increments and direction [see tracing, Fig. 18) permit the establish-
ment of normal basal relationship.

Particularly important in assessing the changing situation are study models

and panoramic and intraoral radiographs.
There are times, though very infrequent, when, with proper guidance and
optimal self-adjustment, the teeth will align themselves and, under the influ-
ence of function and balancing muscle forces, assume nearly normal positions
 Care:L.H.age: 7 8 9 IO 12 13 14 16
SN~AD,ff.
A6 76.5
5.5 75.5
3.0 75.0 740 76fJ 7;; 74.. 75.0
3.0 2.0 3.0
NaS-GoGn 36.0 360 320 36.0 35.0 33.0 33.5 2::
Ul -NaS 1020 83.5 835 915 97.0 97.5 920 95.0
11 -GoGn 89.0 91.5 90.0 909 870 89.5 920 895
Ill-NaPog(mm) 11.5 4.0 4.0 40 50 20 00 I5

__ 7 YRS
---- 8 YRS
/
. . .. .._.__._ 9 YRS
IO YRS
__ IZYRS I
,
---- 13 YRS _ -
-- . . ..__ ,4 YRS
- - 16 YRS

Fig. 18. Same case as shown in Fig. 17. Class II serial extraction problems must be
treated by correcting basal malrelationship as the primary obiective, with guided extrac-
tion procedures secondary. Tracings demonstrate that growth direction is most horizontal
during puberty.

over basal bone, making mechanotherapy unnecessary. Such a case is shown in

Fig. 19. Since this gratifying response is unfortunately t,oo rare, the wise dentist
will continue to rely on the team, getting orthodontic and surgical consulta-
tion before he embarks on a path strewn with indiscriminately removed
deciduous canines, molars, and first premolars.
Problems in serial extraction

There is no form of therapy that does not have its contraindications and
limitations. It has already been emphasized that there is no cookbook for
serial extraction. The timing of tooth removal may be important, and it is not
always possible to see the patient when we want to or to remove specific teeth
at the optimum time for the greatest improvement. The orthodontist must be
prepared to change his treatment plan continually, and the word tedative is
essential for any serial extraction guidance program. Many a potential serial
extraction case has turned out ultimately to require only conventional ortho-
dontic therapy, with no teeth being removed. In some cases, because third
molars were congenitally missing, arch length may have been gained on the
posterior end of the alveolar trough, or the orthodontist may have had the oral
surgeon remove the third molar teeth to gain t.his space. In some instances,
where mandibular arch length is almost adequate, the orthodontist is willing to
accept minor irregularities of the lower incisors and remove only the maxillary
568 Grnber

Fig. 19. Diagnostic records indicated a large incisor liability, and the maxillary right ca-
nine was blocked out of the arch. Guided extraction procedures were instituted. I\lote
deer: jening overbite in second row, with spontaneous improvement thereafter. The
ph\ rsiologic raising of the bites7 frequently occurs with eruption of second mo lars.
Cast s in the bottom two rows were made 5 years after casts in middle row. No
awl iances were worn.
Vcdume 60 Serial extraction 569
Number 6

Fig. 20. Upper left canine impacted despite serial extraction. Stringent appliance efforts
were employed over a prolonged treatment time to achieve changes seen in middle
and bottom views.

first premolar-s. Orthodontic clinicians will testify to the fact that it is much
easier to close spaces in the first premolar area in the maxillary arch than in
the mandibular arch.
More frequently, the serial extraction patient will come in with better
adjustment in the maxillary arch than in the mandibular arch. Almost alwa.ys
there is the ditch between the permanent canine and the second premolar
in the mandibular arch (Figs. 14 and 16). Whereas the roots of the maxillary
570 Graber Am. J. Ovthod.
December 19il

Fig. 21. This series is important because it exemplifies a frequent phenomenon. An

aPF Barently successful four-premolar treatment with seemingly normal eruption of
ma1 Idibular third molars at 14 years (upper left) shows beginning tipping of tl lese
tee1 *h (middle left) and obvious impaction at 18 years (lower left]. The lower I,ight
thirf d molar was removed because of congenital absence of its opponent. The lower left
thin d molar was surgically uprighted [upper right). The middle photograph was t-r lade
1 n month later, and the lower right one was made 8 months after surgical interveni Con.
This orthodontic surgical teamwork is frequently needed for similar problems.
Volume 60
Number 6 Serial extraction 571

Fig. 21 Contd. For legend, see opposite page.

canine and the maxillary second premolar will parallel themselves fairly well
with autonomous adjustment, this is almost never true in the mandibular
arch.34 It is necessary for the orthodontist to resort to stringent appliance
guidance to close the space and upright the teeth. This is within the realm of
conventional therapy and can be accomplished uniformly with a high level of
success. Treatment procedures usually do not exceed 6 to 12 months of mecha-
notherapy. In other words, in the average serial extraction case, mechanotherapy
is reduced at least 50 per cent in terms of time and effort.
Occasionally, the removal of premolars does not stimulate the distal migra-
 Am. J. Orthod.
572 Grabef Decembel 1971

Fig. 22. Another serial extraction case with impacted mandibular third molars. Surgical
uprighting was done at 17 years, and lower left and upper and lower right views are
taken at yearly intervals. Generally, earlier surgical intervention, or when roots are
about two-thirds complete, is desirable.

tion of canines. Fig. 20 shows a case in which one maxillary canine remained
in a horizontal position and impacted. In such instances, the change in treat-
ment plan requires uncovering the canine surgically, placing some sort of guid-
ing appliance, and literally pulling the tooth down into normal position. Experi-
ence with hundreds of serial extraction cases demonstrates the fact that few
patients follow a normal schedule. Eruption in one quadrant often precedes
eruption in the other three. The experienced clinician learns to wait for Nature
to provide all self-help before rushing in with appliances as the teeth peek
through the tissue-an all too common error for the neophyte. Thus, appliance
placement frequently is postponed until the patient is 13 to 14 years of age,
particularly if the patient is a boy.
Large restorations or caries in second premolar teeth may indicate the
removal of one or more second premolars instead of a first premolar.38 A
discretionary decision should be made on the basis of the restorative status of
the teeth as well as the morphology, which may be highly variable. As
mentioned previously, congenital absence of one or more premolars may also
serve to create a problem and require a change in the conventional serial
extraction procedures (Fig. 16).
Removal of premolars in the mandibular arch may enhance the overbite
tendency. The mandibular incisors align themselves but also tend to move
lingually, increasing the overbite. This may signal the need for holding arches
 Berinl extraction 573

or a bite plate. The orthodontist has the appliances to control this quite ade-
quately, but the tendency should be recognized. This emphasizes again tht
need for mechanotherapy at the end of the guided extraction period.
In cases involving extraction of four first premolars, whether serial guid-
ance has been used or not, the ultimate status of the third molars should be
considered.3g, 4o Parents are often told that easy removal of the first premolars
will enhance the likelihood of the normal eruption of the third molars later
and prevent the traumatic removal of impacted teeth. While this may be true
in some cases, a substantial number of records now indicate that first premolar
removal may actually enhance the impaction and forward tipping of the
mandibular third molars, as Fig. 21 shows. It is important that the orthodontist
continue to observe the erupting third molars following the completion of
mechanotherapy and even the retention phase of guidance. If it appears that
the third molars are imminently impacted, then they may be surgically up-
righted with uniformly good results30 (Fig. 22). Failure to do so means the
loss of all four third molars, making this an eight-tooth extraction case. The
orthodontists responsibility is not over when he removes the appliances.
Orthodontic-surgical teamwork continues until completion of the dentition:
Summary

Serial extraction is a guided, progressive removal of deciduous teeth ahead

of the time that they would normally be shed, robbing Peter to pay Paul to
enlist the fundamental phenomena of adaptability and adjustment. By means
of adaptability, providing room for certain teeth, there is an autonomous ad-
justment in the tooth position in Class I malocclusions. The technique is bio-
logically sound, proven, and should not be considered a compromise. The
objectives of establishing the integrity and proper position of the maxillary
and mandibular incisors with the removal of deciduous canines are valid ones.
The goal is to harmonize the defective tooth system with t,he normal muscle
and bone systems in Class I malocclusions. The removal of deciduous first
molars permits the early eruption of first premolars. If arch length is still
obviously deficient, according to adequate diagnostic information available at
that time, the first premolars are removed to allow the canine teeth to migrate
distally into normal positions and to permit space closure by the mesial drift
of the teeth posterior to the extraction site. In almost all instances, conven-
tional orthodontic therapy is required to complete the alignment of teeth, to
parallel the roots on either side of the extraction space, to eliminate overbit.e,
and to effect residual space closure. However, such mechanotherapy is usually
of significantly shorter duration, it is likely to produce less damage, and the
results are more stable.
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1. Palsson, F.: Foregangare til den 8. K. Serieextraktionen, Odontol. Revy 7: 118-135,
1956.
2. Kjellgren, B.: Serial extraction as a corrective procedure in dental orthopedic therapy,
Trans. Europ. Orthod. Sot., pp. 134.160, 1947-48.
3. Hotz, R.: Active supervision of the eruption of teeth by extraction, Trans. Europ. Orthod.
Sot., pp. 34-47, 1947-48.
574 Graber Am. J. Orthod.
December 1971

4. Hots, R. : Orthodontics in daily practice, Bern, 1962, Hans Huber.

5. Heath, J.: The interception of malocclusion by planned serial extraction, N. 2. Dent. J.
49: 77-88, 1953.
6. Heath, J.: Serial extraction and mechanically guided development, Melbourur~, 1958,
Verona Press.
7. Nance, H. : Serial extraction procedures. Personal communication.
8. Lloyd, Z. B.: A composite case report of Class I malocclusions with insufficient arch length,
AM. J. ORTHOD. 39: 262-267, 1953.
9. Lloyd, Z. B.: Serial extraction as a treatment procedure, AY. J. ORTHOD.42: 728-739, 1956.
10. Dewel, B. F.: Serial extraction in orthodontics: Indications, objectives, and treatment
procedures, AM. J. ORTHOD. 40: 906-926, 1954.
11. Dewel, B. F.: The indications and technique of the edgewise appliance in serial extraction
procedures, Trans. Europ. Orthod. Sot., pp. 84-107, 1956.
12. Dewel, B. F.: Serial extraction: Procedures and limitations, AM. J. ORTHOD. 43: 685-687,
1957.
13. Dewel, B. F. : Extra&& serida en ortodoncia: origenes y conceptos Americanos, Rev. Esp.
Ortod. 1: 13-28, 1971.
14. Dewel, B. F.: A critical analysis of serial extraction in orthodontic treatment, AM. J.
ORTHOD. 45: 424-455, 1959.
15. Mayne, W. R.: Serial extraction as an adjunct to orthodontic treatment (audio-visual
sequence), St. Louis, 1965, American Association of Orthodontists.
16. Ringenberg, Q.: Serial extraction: Stop, look, and be certain, AM. J. ORTHOD. 50: 327-
336, 1964.
17. Hinrichsen, C. F. L.: Serial extraction in mixed dentition orthodontics, Aust. Dent. J.
6: 201-209, 1961.
18. Neumann, B.: Planned serial extraction in orthodontic treatment, Dent. Abstr. 6: 489-490,
1961.
19. Fanning, E. A.: Effect of extraction of deciduous molars on the formation and eruption
of their successors, Angle Orthod. 32: 44-53, 1962.
20. Norman, F.: Serial extraction, Angle Orthod. 85: 149-157, 1965.
21. Seward, F. 8.: Natural closure of deciduous molar extraction spaces, Angle Orthod. 35:
85-94, 1965.
22. Moorrees, C. F. A., Fanning, E. A., and Gron, A. M.: The consideration of dental develop-
ment in serial extraction, Angle Orthod. 33: 44-59, 1963.
23. Heath, J.: Dangers and pitfalls of serial extraction, Trans. Europ. Orthod. Sot. 37: 60-72,
1961.
24. Meese, R. A. : Natures role in serial extraction, Ariz. Dent. J. 9: 134-136, 1963.
25. Lysell, L.: Relationship between mesiodistal crown diameters in the deciduous and
permanent lateral teeth, Acta Odontol. &and. 18: l-11, 1960.
26. Graber, T. M.: Postmortems in posttreatment adjustment, AM. J. ORTHOD. 52: 331-352,
1966.
27. Ringenberg, Q. M.: Influence of serial extraction on growth and development of the
maxilla and mandible, AM. J. ORTHOD. 53: 19-26, 1967.
28. Graber, T. M.: Orthodontics, Principles & Practice, Philadelphia, 1966, W. B. Saunders
Company, pp. 714-739.
29. Graber, T. M.: Diagnosis and panoramic radiography, AM. J. ORTHOD. 53: 799-821, 1967.
31). Peskin, Sidney, and Graber, T. M.: Surgical repositioning of the teeth, J. Am. Dent. ASSOC.
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950 E;. 59th St.

There seems to exist, in the minds of some physicians, and dentists as well, the thought
that the practice of orthodontia is really the art of cosmesis rather than an essential part
of the great healing art. That it is a practice which deals in no small way with attempts
to restore to normal function and normal appearance parts which in themselves are things
of beauty and usefulness really adds greatly to its attractiveness as a life work. However,
conservative surgery, which looks to the preservation or restoration of disabled, deformed,
or diseased parts rather than their removal or complete destruction, has never been denied
kinship by the parent profession. (Watson, Milton T.: Presidents Address, Transactions of
the third annual meeting of the American Society of Orthodontists, Dec. 31, 1903, to
Jan. 2, 1904, p. 6, published by Items of Interest.)