From: Morton Speck [mailto:firstname.lastname@example.org]
Sent: Monday, January 31, 2011 10:04 AM
Subject: Rethinking Bicuspid Extraction Patterns
Before I launch into one of my favorite topics, it’s great to see a refurbished ESCO as well as many of the usual suspects. Thanks Huibi!
Now to cut to the chase!
Most of us consider extracting the four 1st bicuspids in a Cl. 1 crowded case a no-brainer because that tooth is closest to the crowding. However, that is not always the best strategy in the maxillary arch for the following reasons: since the 1st bicuspid is generally larger than the 2nd, the presence of the 1st bicuspid makes the reopening of the extraction site less likely; furthermore, should the space reopen, it is less obvious because of its more distal position; equally important, the difference in the gingival heights of the cuspid and 2nd bicuspid can compromise smile esthetics. The natural juxtaposition of the cuspid and 1st bicuspid results in a much more pleasing appearance.
Maxillary 1st bicuspids are also traditionally removed in single arch extraction cases, most notably in Cl. ll div. 1 cases. For the reasons stated above, I would argue again that the maxillary 2nd bicuspid should be the tooth of choice in most cases. The extraction of the maxillary first molar in single arch extraction cases is also a valid option, but that is the topic for another discussion.
With these considerations, I would ask ESCO readers why they would argue against the removal of maxillary 2nd bicuspids in the majority of cases, and in all cases where this size disparity exists, barring any periodontal considerations.
My guess is that most practitioners avoid removing maxillary 2nd bicuspids, either because they never gave it serious thought, or they were wary of the additional mechanics required and/or the anchorage-taxing problems this protocol entails. But to trade a superior result for treatment expedience, in my view, does a disservice to your patient. I respectfully suggest that if you have consistently favored 1st bicuspid extractions in the situations I have described, that you reconsider your options.
Attached are a couple of slides (click here ESCO) that illustrate the size and gingival height difference in a particular case.