Serial extraction (sequential extraction) is the planned removal, in a set order, of certain baby teeth and then the first premolars (small molars) in selected cases where a severe lack of space is anticipated in advance while the child is in the mixed dentition period. The aim is to make room for the permanent teeth that are erupting and to try to ease crowding on its own. Today it is not a method used for every lack of space; in most children, expansion, observation and other options are considered first. This page explains the general framework that families should know when making a decision.
This information is general; the decision for you is made after an examination.
What is serial extraction, and what is it for?
If the jawbone is too small to comfortably hold all the teeth, the permanent teeth erupt out of order, overlapping or out of position. This is called a lack of space (crowding). The idea in serial extraction is this: in line with the eruption order of the permanent teeth, some teeth are removed at the right times and in sequence, so that the remaining teeth move into the space made for them.
The classic description usually consists of three steps, and each step is decided separately according to the check-up made after the previous one:
- Removal of the baby canines: Creates room for the permanent incisors to align in the front area.
- Removal of the first baby molars: Supports the early eruption of the permanent first premolar.
- Removal of the first premolars: Allows the permanent canine to settle into the space.
This order is an example of a plan, not a calendar. The eruption pace of the teeth differs in every child, and the child is re-evaluated by the doctor before moving from one step to the next.
Which children is it considered for?
Serial extraction comes up only when a certain picture is present as a whole. According to the doctor's assessment, most of the following features are looked for together:
- Marked lack of space: a significant difference between the total width of the teeth and the room in the jaw
- A generally harmonious relationship between the lower and upper jaws
- A facial profile and lip balance that can tolerate extraction
- No problems such as missing or extra teeth, or teeth that are unusually small or large
- No accompanying bite problems such as deep or open bite, or only mild ones
In children whose jaw relationship is not harmonious, for example those whose lower or upper jaw sits markedly back or forward, serial extraction is generally not a suitable path. To understand the relationship between the jaws, you can look at the bite classes page. In addition, extraction is not considered when crowding is mild, when there are gaps between the teeth, or when the jaw is already wide enough.
When is the decision made?
The decision is most often made at around age 7–9, in the mixed dentition period, after the first permanent incisors and molars have erupted. At the examination in this period, the doctor looks at the following:
- Clinical examination and photographs
- Panoramic film and lateral cephalometric film (cephalometry)
- If needed, a dental model or digital scan to measure the tooth–space relationship
- The development and eruption status of the permanent teeth
The age limit is not strict; in some children the assessment is made earlier and in others later. What matters is that the decision is made according to the whole picture rather than a single measurement, with close follow-up. You can read why the first orthodontic check is recommended at these ages in the article on the first orthodontic examination in children.
What are the risks and limits of serial extraction?
Serial extraction can lead to unwanted results if the wrong patient is chosen or follow-up lapses. For this reason, the method is used more selectively today. The main points are as follows:
- It may not be enough on its own: In most children, braces or another orthodontic treatment is also needed after the extractions to arrange the teeth.
- Closure of the spaces: The teeth may not drift in the desired direction, and residual gaps may remain.
- Tilting back of the front teeth: The tendency toward a deep bite may increase.
- Irreversibility: A tooth that has been removed does not come back. If the decision is made at the wrong time or in the wrong case, it is hard to correct.
- Change in development: Jaw growth can follow a different course than predicted, and the plan may be reassessed.
Because of these risks, the most important elements in serial extraction are choosing the right case and having regular check-ups throughout the process. In a child who has had planned extractions, skipping check-ups can seriously affect the result.
Which options are available today instead of serial extraction?
As technology and knowledge in orthodontics have advanced, other options are also evaluated before extraction in children with a lack of space. Which one is suitable depends on the child's age, jaw structure and the degree of crowding:
- Observation and space maintenance: When a baby tooth is lost early, a space maintainer can be used to preserve the space. You can also look at the space maintainer article on this subject.
- Jaw expansion: In a narrow upper jaw, expansion can be done while bone growth continues; see jaw expansion treatment.
- Early intervention: In suitable cases, an early-stage treatment plan is made; see early orthodontic treatment.
- Using the extra space provided by baby molars: The difference in width between the baby molars and the permanent premolars can provide some space in mild crowding.
- Interproximal reduction (IPR): After the permanent teeth have erupted, in mild and moderate crowding, space can be obtained by removing a very small amount of enamel between the teeth.
- A braces or aligner plan, with or without extraction, in the permanent teeth: A full plan is made once all permanent teeth have erupted after adolescence; see when tooth extraction is needed in orthodontic treatment.
Is serial extraction the same as extraction treatment done later?
No. Serial extraction is an approach carried out while the child is still in the mixed dentition and also involves baby teeth. Premolar extraction done after the permanent teeth have fully erupted, in adolescence or adulthood, before braces or clear aligner treatment is a different plan. For the second situation, you can look at the page on clear aligners with extraction cases. The timing, purpose and follow-up of the two approaches differ.
The general approaches at a glance
The table below summarizes the general framework. Whether an option in the table is suitable for your child can be decided only with an examination and X-rays.
| Situation | General approach | When to see a doctor |
|---|---|---|
| Mild lack of space | Observation; in some cases space maintenance, or IPR after the permanent teeth erupt | If teeth erupt overlapping or eruption is delayed |
| Moderate lack of space, narrow upper jaw | Expansion and early intervention are evaluated | If a crossbite or jaw narrowness is noticed |
| Severe lack of space, harmonious jaw relationship | Serial extraction may be considered in some cases; braces may be needed afterward | At the start of the mixed dentition, as early as possible |
| Jaw relationship not harmonious | An appliance for jaw development or another plan; serial extraction is generally not suitable | If the lower or upper jaw looks markedly back or forward |
| Early loss of a baby tooth | Space maintainer or observation | Right after the loss, without waiting |
| All permanent teeth have erupted, lack of space continues | A braces or clear aligner plan, with or without extraction | For full planning after all permanent teeth have erupted |
What should the child and the family expect?
Serial extraction is not a one-time procedure but a follow-up process spread over several years. At each step, the child's X-rays and the state of the teeth are re-evaluated; the family is informed each time and the decision is made together. The extraction is carried out under local anesthesia, appropriate to the child's age; the article on baby tooth extraction may be useful for preparing your child. After the extractions are completed, the settling of the teeth continues to be monitored; in most children, an orthodontic treatment is needed afterward for the final alignment of the teeth. At this stage, fixed braces or clear aligner options are discussed according to the child's age and suitability. For clear aligner options in children, you can look at the Invisalign First page.
Serial extraction does not by itself guide jaw growth, and it does not give the same result in every child. For this reason, it is useful for families to ask the doctor the following questions before deciding: How much lack of space does my child have? What is the limit of the non-extraction options? Will braces be needed after the extraction? How often will the check-ups be? The orthodontic examination question list page can help with these questions.
When should I take my child for an examination?
If your child has front teeth that erupt overlapping, teeth that erupt very early or very late, early loss of baby teeth, the impression that there is no room in the mouth for the permanent teeth, or signs of a narrow jaw, it is appropriate to plan an orthodontic examination at around age 7. An early examination does not always mean treatment; most of the time the aim is to determine the right timing together and to avoid unnecessary intervention. For how examinations are arranged for children, you can look at the children's orthodontist page.
How is the assessment done at our clinic?
At the Funda Sarıkaya Oral and Dental Health Polyclinic, the first meeting for children and families begins with a clinical examination and, if deemed necessary, X-rays and a scan. Funda Pekyılmaz Sarıkaya, specialist orthodontist (Uzm. Dt.), evaluates all options, including serial extraction, according to the child's development; where extraction is not needed, observation or non-extraction methods are explained. The Invisalign system is used at the clinic; service languages are Turkish, English, German and Russian. The clinic is located at Park Oran Ofis in Oran, Çankaya, and is open Monday–Saturday between 09:00 and 20:00. You can call 0312 911 60 36 to make an appointment. For orthodontic examinations in Ankara, you can also take a look at the orthodontist in Ankara page.