Original Article

Effects of Lower Primary Canine Extraction on the

Mandibular Dentition
M. Özgür Sayına; Hakan Türkkahramanb

Abstract: It has been reported that extraction of primary canines causes a slight mesial drift of
the buccal segments, lingual positioning of the incisors, a decrease in arch length, deepening of
the bite, and a slight overall crowding in the arch. The aim of this study was to investigate the
effects of early mandibular primary canine extraction on permanent incisor and first molar posi-
tions, dental and alveolar arch widths, and arch length. Thirty-two patients in the early mixed
dentition stage were evaluated. The treatment group (TG) included 16 patients (11 girls, five boys)
who had more than 1.6 mm of crowding. Mandibular primary canines were extracted bilaterally
in these patients. Another 16 patients (11 girls, five boys) who had less than 1.6 mm of crowding
served as controls (CG). Mandibular dental casts and lateral cephalograms of the patients were
obtained at the start (T0) and at the recall (T1) period of the trial. At the end of the one-year
observation period after removal of lower primary canines, the lower incisors retruded more in the
TG as compared with the CG. However, changes in arch length, arch width, and alveolar width
were similar between the groups. (Angle Orthod 2006;76:31–35.)
Key Words: Extraction; Incisor crowding; Interceptive orthodontics; Mandibular dentition; Pri-
mary canines

INTRODUCTION solved by these mechanisms. Sanin and Savara4 re-

ported that 89% of the subjects with crowding in the
Crowding of the lower anterior teeth is a great con-
early mixed dentition also had crowding in the per-
cern for many patients and their parents, as well as
manent dentition.
clinicians. It has been reported that a period of slightly
Several authors tried to predict further space defi-
crowded mandibular incisors was a normal develop-
ciency so as to take interceptive measures in the early
mental stage and solved by a slight increase in inter-
mixed dentition.4–9 Extracting the primary teeth that are
canine width, labial positioning of the permanent inci-
interfering with the eruption of permanent teeth is one
sors relative to primary incisors, and slight backward
of the treatment choices to resolve lower anterior
movement of the canines into the primate space.1,2
crowding during this period.10 The most commonly in-
Lundy and Richardson3 reported that the mean crowd-
volved tooth in such cases is the primary canine. How-
ing of the lower incisors had decreased by 0.9 mm
ever, clinicians have some questions about the ex-
from the initial eruption of the lower permanent incisors
traction of primary canines at an early stage of dental
to the initial eruption of the permanent canines. How-
development.
ever, crowding of more than 1.6 mm may not be
Mills11 stated that extraction of deciduous canines
caused a slight mesial drift of the buccal segments and
a
Assistant Professor, Department of Orthodontics, Faculty of a mild overall crowding in the arch. Foley et al12 re-
Dentistry, University of Suleyman Demirel, Isparta 32260, Tur-
key.
ported that extraction of primary canines could lead to
b
Assistant Professor, Department of Orthodontics, Faculty of more lingual positioning of the incisors, resulting in a
Dentistry, University of Suleyman Demirel, Isparta 32260, Tur- decreased arch length and deepening of the bite. Prof-
key. fit13 reported that early loss of primary canines required
Corresponding author: M. Özgür Sayın, DDS, PhD, Suleyman space maintainer to prevent lingual movement of the
Demirel Universitesi Dishekimligi Fakultesi, Ortodonti A.B.D,
Cunur, Isparta 32260, Turkey incisors. Moyers14 reported that removal of the primary
(e-mail: sayin@[Link]) canines to achieve incisal alignment should be accom-
Accepted: February 2005. Submitted: December 2004.
panied by an appliance to prevent lingual tipping of the
Q 2006 by The EH Angle Education and Research Foundation, lower incisors. However, these reports were based on
Inc. clinical experience rather than scientific evidence.

31 Angle Orthodontist, Vol 76, No 1, 2006

32 SAYIN, TÜRKKAHRAMAN

TABLE 1. Mean Chronological Ages, Observation Periods and Crowding of the Groupsa
TG (n 5 16) CG (n 5 16)
Mean SD Min Max Mean SD Min Max P
Chronological age (y) 8.94 0.90 7.24 10.43 8.88 0.96 7.17 10.87 .865
Observation period (y) 1.10 0.32 0.42 1.55 1.00 0.30 0.50 1.57 .361
Crowding (mm) 3.32 1.11 1.92 5.39 20.14 0.84 22.02 1.20 .000
a
TG indicates treatment group; CG, control group.

A review of the literature indicated that only a few The following measurements were performed on
studies were designed to evaluate the effects of iso- mandibular dental casts.
lated primary canine extraction on the mandibular den-
tition. However, these studies were performed only on • Crowding: total incisor width was subtracted from
study models15 or on cephalometric radiographs.16 In available space (distance between the mesial sur-
our opinion, both study models and cephalograms faces of deciduous canines).8
should be used for proper evaluation of the effects of • Arch length: the shortest distance between the me-
extractions on the developing dentition. sial contact points of the permanent central incisors
The aims of this study were to investigate the effects to a line connecting the mesial contact points of the
of early mandibular primary canine extractions on: permanent first molars.17
• Intermolar width I: distance between mesiolingual
• Permanent incisor and first molar positions; cusp tips of mandibular first primary molars.
• Dental and alveolar arch widths; • Intermolar width II: distance between mesiobuccal
• Arch length. cusp tips of mandibular second primary molars.
• Permanent intermolar width: distance between me-
MATERIALS AND METHODS siobuccal cusp tips of mandibular first permanent
molars.
A total of 32 patients were evaluated in this study.
• Interalveolar width: distance between mucogingival
All the subjects met the following criteria:
junctions below the buccal grooves of the right and
• Class I skeletal pattern; left mandibular first permanent molars.
• Early mixed-dentition stage (four permanent inci-
sors, primary canines, primary molars, and perma- All the measurements on dental casts were per-
nent first molars were all fully erupted); formed with a dial caliper to the nearest 0.01 mm.
• No congenitally missing permanent teeth; Mandibular cephalometric superimposition was per-
• No premature loss of primary or permanent teeth; formed as described by Bjork and Skieller.18 A hori-
• Minimal loss of tooth dimension by caries or attrition; zontal reference line (HRL) was drawn on the first
• No previous orthodontic treatment. cephalogram from the inferior border of the germ of
the lower second permanent molar to the most inner
The treatment group (TG) included 16 patients who and lower contour of the cortical plate. From this point,
had more than 1.6 mm of incisor crowding. Mandibular a vertical reference line (VRL) was drawn perpendic-
primary canines were extracted bilaterally in these pa- ular to the HRL. These reference lines on the first lat-
tients. Another 16 patients who had less than 1.6 mm eral cephalogram were transferred to the second lat-
of incisor crowding served as controls (CG). Both the eral cephalogram using mandibular reference struc-
TG (mean age 8.94 6 0.90 years) and the CG (mean tures.18 The incisal point of the most protruded man-
age 8.88 6 0.96 years) were composed of 11 girls and dibular central incisor and the most mesial point of the
five boys. In the TG, mandibular dental casts and lat- mandibular first permanent molar were marked on
eral cephalograms of each patient were obtained be- each lateral cephalogram. Horizontal distances of
fore primary canine extraction (T0) and at the end of these points to VRL (parallel to HRL) were measured
the observation period (T1). The CG was fully matched on each cephalogram. Apical point of the incisor was
with the TG in observation periods, sex, and age. also marked, and the inclination of lower incisor to
None of the patients in both groups received any or- HRL was measured (Figure 1).
thodontic treatment during the observation period, and Cephalometric and dental cast measurements were
the arches allowed drifting naturally. The mean ages performed by one author to avoid interobserver vari-
and observation periods showed no significant differ- ability. All measurements of 10 subjects were redone
ence between the groups, but crowding was signifi- two weeks later to determine measurement error. The
cantly greater in the TG (Table 1). reliability coefficients were 0.964 and higher.

Angle Orthodontist, Vol 76, No 1, 2006

LOWER PRIMARY CANINE EXTRACTION 33

RESULTS
Intragroup changes (T0-T1)
In the TG, the only significant change was the retru-
sion of incisors (P , .01) (Table 2). No significant
changes were observed in arch length, intermolar and
interalveolar widths, molar position, and incisor incli-
nation. In the CG, the permanent intermolar width in-
creased (P , .01), permanent first molars moved me-
sially (P , .05), and lower incisors proclined (P , .05)
significantly (Table 3). No significant changes were ob-
served in arch length, intermolar widths I and II, inter-
FIGURE 1. Cephalometric reference points, lines, and measure- alveolar width, and incisor position.
ments. (a) The horizontal distance of lower incisor to vertical refer-
ence line (VRL). (b) The horizontal distance of lower molar to VRL. Intergroup changes (T0-T1)
(c) The inclination of lower incisor in relation to horizontal reference
line. A comparison of the groups is shown in Table 4. In
the TG, the lower incisors retruded more (P , .05)
than they did in the CG. The differences observed in
Descriptive statistics including mean, standard de- arch length, intermolar and interalveolar widths, and
viation, and minimum and maximum values were cal- molar position were not significant between the
culated for all measurements. Intragroup comparisons groups.
were performed with paired t-test. Intergroup compar-
isons were performed with independent samples t-test. DISCUSSION
All the statistical analyses were done by using SPSS In orthodontic practice, early treatment procedures
for Windows release 11.0 (SPSS Inc, Chicago, Ill). aim to minimize further treatment need by applying in-

TABLE 2. Changes in TG from T0 to T1a

TG (n 5 16)
T0 T1
Mean SD Mean SD Paired t-test
Arch length 23.98 2.00 23.77 1.93 0.114
Intermolar width I 25.43 1.26 24.97 0.94 0.063
Intermolar width II 28.79 1.28 28.89 1.21 0.331
Permanent intermolar width 32.77 1.93 33.10 2.10 0.141
Interalveolar width 55.78 1.62 55.90 1.67 0.497
Molar position 33.03 2.52 33.06 2.66 0.904
Incisor position 10.87 3.91 11.49 4.31 0.009
Incisor inclination 82.54 6.69 82.34 7.39 0.663
a
TG indicates treatment group; T0, start of trial; and T1, recall period of trial.

TABLE 3. Changes in CG from T0 to T1a

CG (n 5 16)
T0 T1
Mean SD Mean SD Paired t-test
Arch length 24.48 1.54 24.60 1.73 0.445
Intermolar width I 27.10 2.64 26.54 2.71 0.798
Intermolar width II 30.76 2.15 31.10 2.52 0.218
Permanent intermolar width 35.06 2.79 35.45 3.06 0.004
Interalveolar width 56.49 3.19 56.76 3.00 0.072
Molar position 33.36 2.00 32.98 2.00 0.021
Incisor position 9.89 3.06 9.63 2.97 0.345
Incisor inclination 85.36 6.95 86.61 6.52 0.023
a
CG indicates control group; T0, start of trial; and T1, recall period of trial.

Angle Orthodontist, Vol 76, No 1, 2006

34 SAYIN, TÜRKKAHRAMAN

TABLE 4. Comparison of the Changes from T0 to T1 Between the Groupsa

TG (n 5 16) CG (n 5 16)
T1-T0 T1-T0
Mean SD Mean SD Independent t-test
Arch length 20.21 0.51 0.12 0.62 0.106
Intermolar width I 20.48 0.81 0.06 0.69 0.112
Intermolar width II 0.11 0.42 0.24 0.71 0.532
Permanent intermolar width 0.32 0.83 0.39 0.45 0.792
Interalveolar width 0.12 0.66 0.28 0.57 0.465
Molar position 0.03 0.86 20.38 0.59 0.130
Incisor position 0.63 0.84 20.26 1.08 0.014
Incisor inclination 20.20 1.80 1.25 1.97 0.038
a
TG indicates treatment group; CG, control group; T0, start of trial; and T1, recall period of trial.

terceptive measures. When crowding of the lower la- on study models according to Ghahferokhi et al.24 In
bial segment is the issue, interceptive measures this technique, only crown inclinations can be mea-
sometimes include extraction or disking of the primary sured, and this measurement can be directly affected
canines. If the primary canines are extracted or lost at from the surface anatomy of the incisors. A third factor
an early age, the clinician must recognize its effects may be the length of the observation periods. They
on the developing dentition and take measures if re- observed the groups during a two-year period.
quired. Kau et al15 reported a small increase in intermolar
Gianelly19,20 and Brennan and Gianelly21 reported width after the extraction of primary canines. The re-
that early loss of primary canines required immediate sults of this study also revealed small increases in
intervention to control both arch length and symmetry. both groups. These results are in accordance with re-
On the other hand, Lindsten et al22 reported that chil- sults of Bishara et al,25 who previously reported sig-
dren with loss of deciduous canines at a very early
nificant increases in intermolar width between eight
age did not have larger space deficiencies compared
and 13 years.
with those who lost deciduous canines at a later age.
On the basis of the findings of this study, one may
Kau et al15 investigated the effects of lower primary
tentatively suggest that there may be no need to
canine extractions on the developing dentition and re-
ported that the changes in incisor angulations were take any measures to preserve arch perimeters after
similar for both extraction and nonextraction groups. the extraction of primary canines. However, the results
They also found that arch perimeter was decreased may be valid only for the first year after the extrac-
more in the extraction group and without measuring tion of primary canines. In contrast with previous re-
molar positions attributed this loss to the forward ports,19–21 it is suggested that the extraction or loss of
movement of the molars. primary canines does not need immediate interven-
In this study, only the mandibular arch was taken tion. Longitudinal studies had reported significant de-
into consideration because the mandibular arch gen- crease in arch perimeters from mixed to permanent
erally dictates the strategy for maxillary arch treat- dentitions.19–21,26,27 Therefore, application of lingual
ment.19 Because it had been reported that space clo- arches may be postponed until after spontaneous cor-
sure would have happened six months after the loss rection of lower incisor crowding regarding preserva-
of the tooth,23 the observation periods were approxi- tion of arch perimeters and to overcome the slight re-
mately one year for both groups. trusion of the incisors.
The results indicated that there was more retrusion
of the lower incisors in the TG compared with the CG.
However, changes in molar positions were compara- CONCLUSIONS
ble between the groups. The retrusion of the incisors
seems not to cause a significant decrease in arch • Early extraction of lower primary canines caused a
length. These results seem to contradict the findings slight retrusion of the lower incisors.
of Kau et al.15 Three possible factors may explain this • No significant effect of lower primary canine extrac-
difference. First, their study was a randomized con- tion was determined on arch length, arch width, and
trolled trial, and all subjects had a minimum crowding alveolar width.
of six mm. Another factor may be the methodological • Further studies with longer observation periods are
difference because they evaluated incisor inclination needed to make more global statements.

Angle Orthodontist, Vol 76, No 1, 2006

LOWER PRIMARY CANINE EXTRACTION 35

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