Extraction versus non-extraction has been widely discussed in recent years. In fact it has been discussed for a hundred years. "Extraction" usually means four first bicuspids. When the decision is close concerning whether a given case should have extractions, then the decision must be four second bicuspids. Most orthodontists seldom if ever extract four second bicuspids. Many orthodontists do not know how to proficiently treat a case where second bicuspids have been removed. However, treatment is much easier when second bicuspids have been extracted.

There are several good reasons why the extraction of second bicuspids is preferable to the removal of first bicuspids, but we will discuss only one. In most cases it is highly undesirable (almost a sin) to remove a large multi-rooted upper first bicuspid which resists lateral functional forces, and leave a single rooted second bicuspid which is smaller, has a shorter root and a shorter buccal cusp. The longer buccal cusp on the first bicuspid is much more aesthetically desirable, plus it helps the cuspid produce a rise. Also, the first bicuspid, being larger, provides better first molar interdigitation. Most orthodontists do not use sectional arches. Most orthodontists pit the posterior teeth against the anterior teeth and let them meet in the center "with a bow," and blame poor results on the extraction of teeth.

If one is torn between treating a given patient non-extraction (as one would be with all "neather-land" cases), or removing four bicuspids, the orthodontist would be well advised to extract four second bicuspids. Reason?

There are several ways to remedy an error in judgment when second bicuspids have been extracted, while there is no remedy when treating non-extraction. What are these ways to remedy an error in judgment?

1. Sectional arches with closing loops, pitting the lower first molar against the first bicuspid and cuspid or the molar against just the first bicuspid.
   
2. If the first molar offers more resistance than expected, this can be compensated for by the direction of elastic pull-either Class II or Class III.
   
3. Lower first molars can be pitted against an entire upper arch if necessary.
   
4. If lower molars are pitted against an entire upper arch and light Class II elastics from the closing loop (not the molar hook) are worn at night, the lower molars can be moved forward without displacing the incisors lingually.
   
5. If worse comes to worse the protractor headgear can be used. The idea is that, you do whatever is necessary. You do not allow the incisors to move lingually.
   
6. If the lower incisors are bonded and included in the assemblage in the beginning, it is almost impossible to have the treatment turn out successfully. It is an imperative that the lower incisors remain unbonded until the extraction spaces are closed.

If it is determined that the incisors should not move lingually, by using sectional arches correctly, one can be assured that lower incisors will not move lingually. These teeth can be placed exactly where desired in all cases, if the diagnosis has been correct.

Let us take an example: We are treating a case where second bicuspids have been removed, and we have determined that incisors must not move lingually. The lower first molars are pitted against the first bicuspids and cuspids or molars against just the first bicuspids using sectional arches with closing loops. As treatment progresses, if it is observed that a space is beginning to develop mesial to the cuspids, we must not activate the closing loop, but apply a light Class II elastic at night to the closing loop-not the molar hook.

The reason for not allowing the space to occur mesial to cuspids is that later the incisors will move lingually into the space. The reason for not bonding the incisors in the beginning is that they will help the orthodontist monitor tooth movement-leaving a home base to which the positions of other teeth can be related. By using this technique there is no excuse for allowing lower incisors to move lingually. If lower incisors do not move lingually, facial aesthetics is fully equal to non-extraction, and the teeth are more stable. Please see Fig 1

Fig 1: A second bicuspid extraction case twenty years post treatment

The author realizes that this technique is only one method of controlling the position of lower incisors, but other methods must use these same principles.

It is fervently hoped that this short discourse will help clear up some of the confusion regarding non-extraction versus extraction treatment.

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