For four sixes, revisited

Rarely is the extraction of the four first molars the ideal choice in the course of orthodontic treatment, particularly in older patients. Although this approach can offer distinct advantages in carefully selected patients, it is also associated with a number of well-recognized problems, including the extension of treatment times, anchorage management, and control of second molars during space closure. However, by careful use of contemporary materials and techniques, a high standard of treatment can be achieved, even in patients with complex malocclusions. This is illustrated in a report of a case that highlights both the challenges and some of the solutions this treatment modality can offer. •Extraction of 4 first molars can be considered for carefully selected patients.•Well-planned treatment will add only a few months to treatment duration.•The patient will benefit by ending treatment with 2 premolars in each quadrant.•The need for dental restorations or prosthetic replacement can be avoided.