CONTINUING EDUCATION ARTICLE An occlusal and cephalometric analysis of lower first and second premolar extraction effects

Brittany N. Shearn, BAppSc(Med Rad), MDSc,a and Michael G. Woods, DDSc, FRACDS, FRACDS(Orth), DOrth RCS(Eng)b Melbourne, Australia This study was designed to examine lateral cephalometric and arch dimensional changes that occur in the mandibular arch during orthodontic treatment involving the extractions of various premolars. Pretreatment and posttreatment records of 73 patients were chosen at random from completed cases in the practice of one experienced orthodontist. Eighteen involved the extraction of lower first premolars, and 55 involved the extraction of lower second premolars. Of these 55, 29 involved the extraction of upper first premolars and 26 involved the extraction of upper second premolars. In the lower first premolar group, however, all 18 involved the extraction of upper first premolars. Males and females were evenly represented in the 3 subgroups. Pretreatment factors that suggested a basis for the extraction choice in this group of patients were found to include incisal overjet, molar relationship, and underlying vertical facial pattern. A wide variety of arch dimensional changes was found with different lower premolar extraction patterns. There was evidence, however, of more intermolar arch width reduction after the extraction of lower second premolars than lower first premolars. Orthodontic treatment with the extraction of premolars did not consistently cause a retrusive effect on the incisors. In fact, instances of proclination of the incisors occurred within all of the extraction groups. A large amount of individual variation in incisor and molar changes accompanied treatment involving all lower premolar extraction patterns. (Am J Orthod Dentofacial Orthop 2000;117:351-61)

The indications for extractions in orthodontic practice have historically been controversial. It has
1-6

been suggested that, through advances in technique and research, the ability to control the movement of teeth in 3 dimensions and to correlate these movements with anticipated facial growth changes have expanded the variations in extraction sequences.7 However, the relative efficacy of various extraction or nonextraction strategies, in either the short-term or the long-term, have yet to be fully established.8 Premolars are probably the most commonly extracted teeth for orthodontic purposes, conveniently located between the anterior and posterior segments. Variations in extraction sequences including upper and lower first or second premolars have been recommended by different authors for a variety of reasons.7-13 It is well documented that arch dimensional changes occur with orthodontic treatment after the extraction of teeth and that these dimensions also continue to change
aIn

private practice in orthodontics. Professor and Head of Orthodontics, The University of Melbourne. Reprint requests to: Associate Professor Michael Woods, Orthodontic Unit, School of Dental Science, The University of Melbourne, 711 Elizabeth Street, Melbourne 3000; e-mail, m.woods@dent.unimelb.edu.au Copyright 2000 by the American Association of Orthodontists. 0889-5406/2000/$12.00 + 0 8/1/102545 doi:10.1067/mod.2000.102545
bAssociate

after the end of active treatment.13-16 Quantification of these changes and ones ability to use the space created in a predictable fashion have not, however, been widely documented in the literature. For instance, in one study, Luppanapornlarp and Johnston15 noted a long-term average arch length reduction of 2 to 3 mm after treatment for most patients, independent of the nature of the malocclusion being treated or the treatment strategy used. Postorthodontic decreases in intercanine width have also been noted by some investigators.17-20 Because it is widely accepted that there is a strong relationship between root surface area and anchorage potential, the choice of teeth to be extracted should have a direct effect on the amount of anterior segment retraction.21-24 Proffit23 sought to quantify differences in incisor retraction and mesial molar movement with different extraction patterns through clinical observation. He stated that all other things being equal, the amount of incisor retraction will be less, the further posteriorly in the arch an extraction is located, and that even with second premolar extraction, some retraction of the lower incisors may occur, but most of the space closure will be by mesial movement of the lower molars. This effect of treatment on the position of the lower incisors has also been reported, especially in retention with respect to various anteroposterior planes
351

352 Shearn and Woods

American Journal of Orthodontics and Dentofacial Orthopedics March 2000

Table I. Population Group

sample
N 73 36 37 18 55 26 29 Mean age of commencement in years (months) 13.7 (164) 13.8 (166) 13.5 (162) 13.6 (163) 13.6 (164) 14.0 (168) 13.8 (166) Mean treatment time in years (months) 2.3 (27) 2.3 (27) 2.2 (26) 2.3 (28) 2.2 (26) 2.2 (26) 2.2 (26)

Total Males Females Extraction lower 4s 4/4 Extraction lower 5s 5/5 4/5

*Extractions: 4/4 upper 4s, lower 4s; 5/5 upper 5s; lower 5s; 415 upper 4s; lower 5s.

Table II. Pretreatment Variable

variables group 4/4

Mean 163.1 28.1 3.3 3.6*** 3.3 1.7** 87.8* 36.2 29.9 3.4 SD 15.7 3.9 2.8 2.1 1.8 2.9 4.0 6.1 8.2 3.0 Minimum 139.0 21.0 2.7 1.0 1.0 3.0 79.0 26.6 14.4 1.8 Maximum 199.0 34.0 7.7 8.0 6.0 6.5 95.4 47.9 48.9 9.6

Age (months) Treatment time (months) ANB () Overjet (mm) Overbite (mm) CII molar relationship (mm) Facial axis () SNMP () T1 APo 31/41 () Crowding (mm)

ANOVA: *Significant at P < .05; **significant at P < .01; ***significant at P < .001.

Table III. Pretreatment variables group 5/5 Variable Age (months) Treatment time (months) ANB () Overjet (mm) Overbite (mm) CII molar relationship (mm) Facial axis () SNMP () T1 APo 31/41 () Crowding (mm) Mean 161.9 26.3 3.2 2.9*** 3.5 0.3** 89.5* 34.5 27.2 3.6 SD 15.0 4.6 2.5 1.3 1.4 2.8 4.4 6.9 5.1 2.4 Minimum 137.0 14.0 3.0 0.5 1.0 6.0 81.3 14.3 19.5 0.6 Maximum 200.0 38.0 7.8 6.0 6.5 8.0 98.5 46.3 38.7 10.7

ANOVA: *Significant at P < .05; **significant at P < .01; ***significant at P < .001.

of reference.15,20,22,25 In addition, some authors26-28 have reported definite correlations between incisor movements and soft tissue changes. Others have found that proportional changes in the soft tissue do not necessarily follow changes in the dentition.29-31 One must remember that changes in profile include the effects of both treatment and growth, as growth of the nose and chin alter significantly during adolescence and continue to change throughout life. It has often been claimed that extraction treatment has a flattening effect on the facial profile. This has been recently supported by the

findings of some clinical studies.32,33 However, it has not been supported by others.15 The long-term stability of various treatment-induced changes in arch dimensions has been questioned, and lower intercanine width, in particular, has been considered immutable.17,34,35 It is evident from all of these studies that there are some predictable differences in the dental and facial effects of extraction and nonextraction treatment. Unfortunately, the impact of various extraction sequences on these areas has largely been by clinical observation, and there is little scientific evidence to support the choice

American Journal of Orthodontics and Dentofacial Orthopedics Volume 117, Number 3

Shearn and Woods 353

Table IV. Pretreatment Variable

variables group 4/5

Mean 166.3 26.0 2.7 4.9*** 3.8 2.6** 90.1* 34.1 26.3 3.0 SD 16.2 7.2 2.4 1.9 1.3 3.6 3.4 5.2 4.9 2.5 Minimum 140.0 14.0 2.7 1.5 1.5 3.0 81.7 22.8 15.5 4.4 Maximum 204.0 44.0 6.1 9.0 6.0 11.0 95.7 44.1 33.1 9.0

Age (months) Treatment time (months) ANB () Overjet (mm) Overbite (mm) CII molar relationship (mm) Facial axis () SNMP () T1 APo 31/41 () Crowding (mm)

ANOVA: *Significant at P < .05; **significant at P < .01; ***significant at P < .001.

Table V. Cephalometric Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Measurement

measurements
Definition Angle formed by the intersection of nasionA point and nasionB point lines Angle formed by the intersection of sellanasion line and the gonionmenton line Angle formed by the intersection of the basionnasion line and the facial axis Angle formed by the intersection of the long axes of the upper and lower central incisors Angle formed by the intersection of the long axis of lower incisor and the corpus axis Horizontal distance from the lower incisor tip to the A pointPogonion line Angle formed by the intersection of the long axis of the lower incisor and the A pointpogonion line Perpendicular distance from B point to pterygomaxillary line at B Perpendicular distance from pogonion to pterygomaxillary line at Pog Distance between Xi point and suprapogonion Distance between articulare and pogonion Angle formed by the A pointpogonion line and the pterygomaxillary line Vertical distance between menton and lower incisor tip From the superimposition on corpus axis at suprapogonion, the horizontal distance between lower incisor tip initial and lower incisor tip final, perpendicular to pterygomaxillary line.

ANB () SNMP () FA () IA () 1CA () 1APo (mm) 1APo () BB (mm) PogPog (mm) ML (mm) CL (mm) APovertical ref () Lower dental height (mm) Incisal tip change (mm)

of one sequence over another. With this in mind, the present study has been designed to investigate the differences in lower arch-dimensional and arch-positional changes after orthodontic treatment that involves the extractions of either lower first or second premolars.
MATERIAL AND METHODS Population Sample

treatment lateral cephalographs and study casts and details of the treatment history.

The experimental sample consisted of pretreatment and posttreatment records of 73 extraction cases treated by one experienced orthodontist with preangulated fixed appliances (0.018 ! 0.028 inch). The cases were selected on the basis of the following criteria:
1. All patients had undergone mandibular premolar extraction as part of a comprehensive orthodontic treatment plan. 2. None of the patients had any adjunctive appliance such as a Quad Helix, a functional appliance, or a rapid palatal expander used as part of their orthodontic treatment. 3. All cases included a minimum of pretreatment and post-

The number of subjects in the total population sample and its subgroups are listed in Table I. Ages at commencement and completion of active treatment and the numbers in various extraction subgroups are also shown. The average length of treatment in fixed appliances was 2.2 years with a range of 1.2 to 3.7 years. So that changes from any initial group differences could be distinguished from actual treatment effects, several pretreatment variables were evaluated. The 3 extraction subgroups (Tables II to IV) were then compared statistically and the differences were quantified using a one way analysis of variance (ANOVA). Three measurements were identified as significantly different, among the groups at the 95% confidence level. These areas included two study model measurements, incisal overjet and Class II molar relationship, and one cephalometric measurement, the facial axis. The 4/4 group, for

354 Shearn and Woods

American Journal of Orthodontics and Dentofacial Orthopedics March 2000

Fig 1. Cephalometric measurements (1-4).

Fig 2. Cephalometric measurements (5-13).

instance, seemed to be more dolichofacial than the other groups and had moderate amounts of overjet and molar correction to be achieved. The 4/5 group had the largest mean overjet of 4.9 mm and the greatest mean Class II molar relationship. The 5/5 group had the smallest mean overjet of 2.9 mm and a mean Class I molar relationship.
Cephalometric and Occlusal Analysis

The cephalometric measurements used in this study are described in Table V and illustrated in Figs 1 to 3. All radiographs were traced over a 2-week period, under the same viewing conditions, in a darkened room with a light box with extraneous light blocked out. Measurements were made with the Westcef program,* which automatically rotates the digitized points so that the pterygomaxillary (PM) line through sphenoethmoidale is vertical (Fig 1). Absolute distances were measured from point to point. Horizontal and vertical distances between points were measured relative to the X and Y coordinates of those points. After digitization, all data were stored in an Excel spreadsheet. As required, tracings were superimposed on the corpus axis registered at suprapogonion (SPog) (Fig 3) as described by Ricketts,36 and as previously shown to be acceptable.37 Once the corpus axis superimposition had been made, incisal changes were measured perpendicular to the PM vertical reference

plane with forward movement of the incisal tip being assigned a positive value. The study cast measurements used in this study are described in Table VI and illustrated in Fig 4. Various occlusal landmarks were identified for each lower study cast (Fig 4) so that a digital caliper (Mitutoyo Digimatic Caliper) could be used to measure distances between points. The results were then directly entered into an Excel spreadsheet. The amount of crowding was not simply estimated from the pretreatment study casts. Instead the space required for alignment and leveling was determined with the segmental method of Proffit,23 by subtracting the pretreatment segmental total from the posttreatment total, then adding back in the actual mesiodistal widths of the 2 extracted premolars. The residual space was then calculated by subtracting the amount of space required from the sum of the mesiodistal widths of the extracted lower premolars.
Error Study and Treatment of Data

*A customized lateral cephalometric research analysis program, Mr Geoffrey West, The University of Melbourne.

In order to evaluate tracing and measurement error, the records of 10 patients (20 radiographs and 20 sets of study casts) were selected at random. From the results of the Student t test, at the 95% confidence interval, no significant differences could be found between the first and the second sets of measurements. The mean error for angular and linear cephalometric measurements ranged from 0.02 to 0.6 and 0.01 to 0.5 mm, respectively. The mean error for intra-arch and inter-arch linear measurements ranged from 0.1 to 0.5

American Journal of Orthodontics and Dentofacial Orthopedics Volume 117, Number 3

Shearn and Woods 355

Fig 4. Arch-dimensional measurements (18-22).

depth and chordal arch length reductions were remarkably similar for all groups. The only statistically significant difference found was for the reduction in intermolar width. The mean of 2.8 mm ( 1.9) in the lower first premolar group was smaller than the lower second premolar group, which had a mean reduction of 4.4 mm ( 2.0).
Lower Incisor Position and Angulation Changes

Fig 3. Lower incisor tip changes. (Superimposition on corpus axis at suprapogonion.)

mm. Other studies have reported similar error measurements.38-40 Mean changes were calculated for each cephalometric and study cast variable. Analysis of variance was then used to search for any statistically significant differences in changes among the 3 subgroups. Where applicable, the strength of any association was further quantified by calculating Pearsons product moment correlation coefficients (r).
RESULTS Arch Dimensional Changes

A summary of the lower arch dimensional changes for all of the groups is outlined in Table VII. Because there was no statistical evidence of sexual dimorphism, each of the extraction subgroups was not further divided into male and female subgroups. The mean intercanine width in each group underwent little change. In the overall female and the lower first premolar extraction groups, the mean represented a slight increase in intercanine width compared with other groups, but the mean arch

Although no statistically significant differences were found, some trends were evident in lower incisor positional changes (Table VIII). There was an overall mean reduction of 1.3 mm of the lower incisors in relation to the APo reference line when any lower premolars were extracted. The 4/4 group had the greatest mean incisor retraction of 2.4 mm, whereas the 4/5 and 5/5 had mean retractions of 1.4 mm and 0.5 mm, respectively. Similarly, the angulation of the lower incisors to the APo line showed the same sort of mean trends; the 4/4 group had the greatest mean change. The standard deviations for this measurement, however, were larger, which indicated a greater degree of individual variation in angulation change. The mean lower incisor angulation changes on the bone itself (corpus axis superimposition) showed similar trends, with more retroclination after the extractions of lower first premolars than lower second premolars. Once again, the standard deviations were quite large. Interincisal angulation increased on average as a result of likely changes in angulation of both upper and lower incisors with very large standard deviations. The mean lower dental height from the lower incisor tip to menton increased in all groups; the increase was greater in the lower first premolar extraction group with little difference between the two lower second premolar groups.
Lower Incisor Superimposition

The frequency of anteroposterior changes recorded at the lower incisor tip when pretreatment and posttreatment tracings were superimposed on the corpus

356 Shearn and Woods

American Journal of Orthodontics and Dentofacial Orthopedics March 2000

Table VI. Study Number 15 16 17 18 19 20 21 22

cast measurements
Definition Vertical measurement of the overlap of the upper and lower incisors Horizontal distance between the upper and lower incisors Calculated by subtracting the pretreatment segmental total from the posttreatment segmental total, then adding back in the mesiodistal widths of the 2 extracted premolars Distance from the mesial contact point of the lower first molars to the contact point of the lower central incisors Perpendicular distance from the line joining the mesial contact points of the lower first molars to the contact point of the lower central incisors Horizontal distance between the tips of the lower canines Horizontal distance between the mesiobuccal cusp tips of the lower first molars Distance between the lines perpendicular to the contact points of a segment of teeth; between the first molar and the distal surface of the lateral incisor and between that distal surface and the mesial surface of the central incisor Distance between the mesiobuccal cusp tip of the upper first molar and the buccal groove of the lower first molar

Measurement Overbite (mm) Overjet (mm) Crowding (mm) Chordal arch length (mm) Arch depth (mm) Arch width 33 (mm) Arch width 66 (mm) Arch segments (mm)

23

Molar relationship (mm)

Table VII. Lower Group Total Males Females Exo 4s Exo 5s 4/5 5/5

archdimensional changes with treatment

N 73 36 37 18 55 29 26 Arch depth (mm) 5.5 1.8 5.5 1.8 5.5 1.7 5.8 1.9 5.4 1.7 5.7 1.9 5.2 1.5 Chordal arch length (mm) 11.2 2.9 11.4 3.5 11.1 2.5 11.1 3.2 11.2 2.9 11.6 3.5 10.8 2.2 Arch width 33 (mm) +0.01 1.6 0.3 1.7 +0.3 1.5 +0.5 1.8 0.2 1.6 0.1 0.5 0.2 1.7 Arch width 66 (mm) 4.0 2.0 4.1 2.0 3.9 2.1 2.8 1.9** 4.4 2.0** 4.4 1.9 4.4 2.0

Student t test; **P < .01.

Table VIII. Lower Group Total Males Females Exo 4s Exo 5s 4/5 5/5

incisor position and angulation changes with treatment

Lower incisor position APo (mm) 1.3 2.7 1.6 3.2 1.1 2.2 2.4 3.1* 1.0 2.5 1.4 2.2* 0.5 2.9* Lower incisor angulation APo () 0.5 7.0 1.5 7.6 +0.4 6.1 2.5 8.3 +0.1 6.4 0.5 7.0 +0.8 5.8 Lower incisor angulation corpus axis () 1.7 6.6 2.8 7.1 0.6 6.0 4.0 7.4 1.0 6.8 1.9 7.4 +0.1 6.4 Lower dental height (mm) +2.2 2.8 +2.6 2.4 +1.8 3.1 +3.2 2.6 +1.8 2.8 +2.0 2.9 +1.7 2.8 Interincisal angulation () +5.4 11.2 +6.1 12.0 +4.7 10.4 +8.8 14.1 +4.3 10.0 +5.6 10.6 +2.9 9.1

*ANOVA, P = .07. Student t test, P = .06.

axis at SPog are illustrated in Fig 5. It is evident that, for each group, there was a wide range of individual changes, although there appeared to be a trend in which more incisor retraction was seen in lower first premolar extraction cases.
Molar Versus Incisor Changes

The anteroposterior component of the change in lower molar position was estimated by calculating the

difference between the arch depth change (mm) and the change in incisor position (mm) (from the superimposition at corpus axis on SPog). Mean changes in estimated molar movement were then calculated for each group and found not to be significantly different. The means for all groups ranged from 4 to 4.5 mm of forward lower molar movement. The incisors were actually retracted from their pretreatment positions in 60%, 65%, and 50% of cases within the 4/4, 4/5, and 5/5

American Journal of Orthodontics and Dentofacial Orthopedics Volume 117, Number 3

Shearn and Woods 357

Fig 6. Occlusal and lower incisor anteroposterior changes 4/4 extraction sequence. Individual Variation

Fig 5. Frequency of lower incisor anteroposterior movement. (Superimposition on corpus axis at suprapogonion.)

groups, respectively. Furthermore, comparing relative amounts of movement, the incisors had undergone greater movement than the first molars in 38%, 20%, and 6% of cases within these groups. Finally, little if any incisor retraction was found in 16%, 14%, and 15% of cases within these groups.

Because of the wide range of individual variation found in each of the groups, it was decided to look for any similarities that might exist among the individuals who had shown extremes of incisor movement within each group. Three individuals were therefore taken from each extraction group, one in whom the incisors were retracted the most, another in whom there was the most proclination, and the third in whom there was no incisor change at all (Table IX, Figs 6 to 8). Some trends are evident among these individuals. For example, in the individuals in whom the incisors were retracted the most, there generally seemed to be less crowding. Similarly, there seemed to be greater retraction of the lower incisors when greater residual space remained, after resolution of the crowding. In the indi-

358 Shearn and Woods

American Journal of Orthodontics and Dentofacial Orthopedics March 2000

Fig 7. Occlusal and lower incisor anteroposterior changes 4/5 extraction sequence.

Fig 8. Occlusal and lower incisor anteroposterior changes 5/5 extraction sequence.

viduals that showed the greatest forward incisor movement, there was more than 5 mm of crowding. It was interesting to note that changes of incisors on the underlying bone were not necessarily reflected in the final lower incisor position in relation to APo. For example, individual E with 3 mm of incisor forward movement on the underlying bone had a final APo position that was less than the initial. Obviously changes were occurring in the positions of point A and pogonion at the same time.
Further Correlations

the estimated forward movement of the lower molars. These findings are not unexpected as all these measurements are somewhat dependent on each other. There was no significant correlation evident with any of the other variables investigated.
DISCUSSION

When Pearsons correlations were carried out, 3 variables appeared to correlate quite strongly with changes in lower incisor position on bone (Table X). These included changes in interincisal angulation, changes in lower incisal angulation to corpus axis, and

Before considering the changes found in this study, it is interesting to note that there were considerable differences in the pretreatment characteristics of the experimental groups. The patients in the 4/4 group, for instance, had a mean facial axis 1 standard deviation more dolichofacial than those in either of the lower second premolar groups. When the second premolar extraction group was further subdivided, depending on the extraction pattern in the upper arch, differences

American Journal of Orthodontics and Dentofacial Orthopedics Volume 117, Number 3

Shearn and Woods 359

Table IX. Individual Extraction sequence 4/4 Individual A Individual B Individual C 4/5 Individual D Individual E Individual F 5/5 Individual G Individual H Individual I

variation in incisor movement

Crowding (mm) Residual space (mm) Initial molar relationship Initial lower incisor APo (mm) Final lower incisor APo (mm)

Incisor movement (mm) (superimposition)

7 +7 0 4 +3 0 5 +4 0

1.8 9.6 7.5 4.4 5.6 4.5 2.4 6.6 1.1

16.0 5.2 8.3 20.2 9.8 10.3 13.5 8.2 13.5

II I II II II II II I I

11.3 0.4 3.2 3.2 0.5 4.4 1.0 4.1 4.5

3.6 6.8 2.4 2.6 2.7 3.3 4.2 2.1 2.9

Table X. Correlations Variable 1

with lower incisor movement (superimposition)

Variable 2 Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Lower incisor movement Pearsons correlation (r) 0.6* 0.4 0.6* 0.1 0.02 0.02 0.3 0.2 0.4 0.3 0.1 0.01 0.2 0.8*

Interincisal angulation change () Crowding (mm) Lower incisor corpus axis change () Pogonion change (mm) Mandibular length change (mm) Mandibular plane (SNMP) change () Initial lower incisor APo () APo to vertical reference change () Residual space (mm) Initial lower incisor Apo (mm) Initial molar relationship (mm) Age (months) B point change (mm) Estimated molar movement (mm) *Significant correlations.

were even more obvious. The data suggest that the extraction sequence decisions were influenced, at least in part, by 3 main variables: incisal overjet, molar relationship, and underlying vertical facial pattern. This is in contrast to previous studies32,41 in which extraction versus nonextraction pretreatment variables have been considered and that have reported tooth-size archlength discrepancy or crowding to be the most significant factors influencing the extraction decision. There do not seem to have been any previous reports in the literature that suggest pretreatment vertical facial pattern factors as indicators toward the choice of extraction sequences. One would, however, expect there to be such skeletal and muscular criteria by which particular extraction sequences might be chosen by clinical orthodontists. In fact, similar criteria to those uncovered in the present study may have become evident in previous studies if the authors had considered specific extraction

sequences, rather than simply comparing overall extraction and nonextraction treatment. As a result, discussion regarding the choice of particular extraction sequences has previously been based largely on anecdotal clinical opinions.7,23 In the present study, arch-dimensional changes in each group, in general, involved a contraction of the lower arch in both transverse and anteroposterior dimensions. Both chordal arch length and arch width were consistently reduced, on average, in all groups. This would be expected as similar amounts of crowding occurred in each group and resulted in similar amounts of overall residual arch space. The mean chordal arch length reduction of 11.2 mm was similar to that previously reported by De La Cruz et al42 but greater than that reported by Luppanapornlarp and Johnston.15 This latter group reported a mean reduction of 8.6 mm in chordal arch length during treatment in

360 Shearn and Woods

American Journal of Orthodontics and Dentofacial Orthopedics March 2000

premolar extraction cases. Assuming that all arch forms remained approximately the same, this difference may mean that the patients in that sample had greater pretreatment crowding on average. When one considers the intermolar width changes, significantly greater mean contraction of the first molars was found in the 5/5 group. This may be due to increased forward molar movement in this group. It may also suggest that maintenance of initial lower molar width may be easier when the second premolars have not been extracted. It is interesting to compare the lower incisor retraction changes with figures reported by Luppanapornlarp and Johnston,15 who found a 2 to 3 mm retrusive effect on the incisors with lower premolar extractions. In addition, they reported that lower first premolar extractions had on average a 3 mm retrusive effect, compared with a 2 mm retrusive effect for lower second premolar extractions. Similar mean findings were found in the present study, with a mean retrusive effect of 2.4 mm with lower first premolar extractions and 1.0 mm with lower second premolar extractions. However, it is important to note that, although the means in both studies were similar, there was considerable individual variation found in this study. It is likely that, although not reported, the same wide range of effects would have been evident in the Luppanapornlarp and Johnston sample.15 The mean changes in the positions of the lower incisors in relation to the APo line appear to vary somewhat according to the extraction sequence, unlike their changes in position on the bone (corpus axis at SPog), which do not seem to follow any specific pattern. Therefore it is evident that there is some further interaction between lower incisor movement, anteroposterior and vertical movement of the chin, and any treatment effect at point A. In view of the wide range of individual variation, however, it is difficult to determine the precise influence that these factors might have in any individual patient. Differences in the lower dental height changes were evident in the 2 lower extraction groups, with a greater increase in lower dental height evident after the extraction of lower first premolars. The results may be explained at least in part by the greater proportion of dolichofacial patients in the first premolar extraction group, with greater necessary vertical dentoalveolar compensation with growth resulting in this greater lower dental height. From concepts previously documented in the literature,20-22,24 one might have expected to have found greater forward molar movement in general after the extraction of lower second premolars. In fact, when relative incisor and molar movements were compared in

this study, greater molar movements did occur in 79% and 66% of the 2 lower second premolar extraction groups, respectively, whereas those greater molar movements only occurred in approximately 50% of the lower first premolar extraction cases. One must still recognize that despite these findings, there was considerable individual variation in lower molar behavior within each group. It is quite evident from the results of this study that significant individual variation exists in the response to orthodontic treatment with any of the extraction sequences investigated. This was especially evident when extremes of incisor movement were considered (Table IX). It seems possible to achieve a variety of incisor changes with each of the extraction patterns, although there do appear to be some definite trends. For instance, patients in whom maximum incisor retraction occurred in each of the groups had consistently less crowding and greater residual space than the other patients. It seems that the crowding and residual space were just as important, if not more important, in determining final tooth positions than the choice of extraction sequence itself. Proffit23 suggested that all other things being equal particular trends exist regarding the likely incisal effects from various premolar extraction patterns. All things are seldom equal, however, with individual patients presenting with different malocclusions, with different underlying anteroposterior and vertical facial patterns, at different ages, and at different stages of development. Because the individual variation shown in this study would support the fact that effects of treatment achieved with the same extraction sequences are not clearcut, it is important that all these other things are taken into account when making a detailed treatment plan, rather than simply choosing an extraction sequence on the basis of simplistic expectations of published mean incisal changes.
CONCLUSIONS 1. Pretreatment factors other than crowding, which with hindsight might suggest a basis for lower premolar extraction choice, include incisal overjet, molar relation, and underlying vertical facial pattern. 2. A wide variety of arch-dimensional changes is possible with different lower premolar extraction patterns. It is likely that greater intermolar arch width reduction will occur after the extraction of lower second premolars than lower first premolars. 3. Orthodontic treatment with the extraction of premolars does not consistently cause a retrusive effect on the lower incisors. In fact, proclination of the incisors may occur with any lower premolar extraction pattern. A large

American Journal of Orthodontics and Dentofacial Orthopedics Volume 117, Number 3

Shearn and Woods 361

amount of individual variation of incisor and molar changes accompanies treatment involving all lower premolar extraction patterns. 4. There is generally more forward movement of the lower molars than incisal retraction with the extraction of lower second premolars than with the extraction of lower first premolars, although a specific extraction pattern does not necessarily guarantee certain amounts of incisor retraction or lower molar forward movement. 5. It is evident that there is much individual variation in response to growth and treatment created by differences in choice of treatment mechanics and different facial and occlusal objectives, depending on pretreatment characteristics as well as the extraction sequence itself.

15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

We thank Ms Florence Choo from the Statistical Consulting Center at The University of Melbourne for her assistance with statistical analysis. We also acknowledge the work of Mr Geoffrey West for the production of the Westcef cephalometric analysis program used in this study.
REFERENCES 1. Angle EH. Malocclusion of the teeth, 7th ed. Philadelphia: S S White Dental Manufacturing Co, 1907. 2. Begg PR. Stone age mans dentition. Am J Orthod 1954;40:298-312. 3. Case CS. The question of extraction in orthodontia. Am J Orthod 1964;50:660-91. 4. Case CS. The extraction debate of 1911 by Case, Dewey, and Cryer. Discussion of Case: the question of extraction in orthodontia. Am J Orthod 1964;50:900-12. 5. Hahn G. Extraction Panel. Orthodontics: Its objectives, past and present. Am J Orthod Oral Surg 1944;20:401-4. 6. Tweed C. Indications for the extraction of teeth in orthodontic procedure. Am J Orthod 1944;30:405-28. 7. Brandt S, Safirstein R. Different extractions for different malocclusions. Am J Orthod 1975;68:15-41. 8. Weintraub J, Vig P, Brown C, Kowalski C. The prevalence of orthodontic extractions. Am J Orthod Dentofacial Orthop 1989;96;462-6. 9. De Castro N. Second premolar extraction in clinical practice. Am J Orthod 1974;65:115-37. 10. Neff CW. Tailored occlusion with the anterior coefficient. Am J Orthod 1949;35:309-14. 11. Rees D. A method for establishing the proportional relation of apical bases and contact diameters of the teeth. Am J Orthod 1953;39:695-707. 12. Lundstrom A. Intermaxillary tooth width ratio and tooth alignment in occlusion. Acta Odontol Scand 1954;12:265-92. 13. Saatci P, Yukay F. The effect of premolar extractions on tooth-size discrepancy. Am J Orthod Dentofacial Orthop 1997;111:428-34. 14. Paquette DE, Beattie JR, Johnston LE. A long-term comparison of nonextraction and

26. 27. 28. 29.

30. 31. 32.

33. 34. 35. 36. 37.

38. 39. 40. 41. 42.

premolar extraction edgewise therapy in borderline Class II patients. Am J Orthod Dentofacial Orthop 1992;102:1-14. Luppanapornlarp S. Johnston L. The effect of premolar extraction: a long-term comparison of outcomes in clear-cut extraction and nonextraction Class II patients. Angle Orthod 1993;63:257-72. Staggers J. Vertical changes following first premolar extractions. Am J Orthod Dentofacial Orthop 1994;105:19-24. Bishara S. Chada J, Potter R. Stability of intercanine width, overbite, and overjet correction. Am J Orthod 1973;63:588-95. Shapiro P. Mandibular dental arch form and dimension. Am J Orthod 1974;66:58-70. Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention. Am J Orthod Dentofacial Orthop 1988;93:423-8. Carter N. First premolar extraction and fixed appliances in the Class II division 1 malocclusion. Br J Orthod 1988;15:1-10. Williams R, Hosila F. The effect of different extraction sites upon incisor retraction. Am J Orthod 1976;69:388-410. Steyn C, du Preez R, Harris A. Differential premolar extraction. Am J Orthod Dentofacial Orthop 1997;112:480-6. Proffit WR. Contemporary orthodontics, 2nd ed. St Louis: MosbyYear Book; 1993. Schwab D. Extractions in borderline cases. Am J Orthod 1963;33:120-2. Bishara S, Cummins D, Jakobsen J. The morphological basis for the extraction decision in Class II, Division 1 malocclusions: a comparative study. Am J Orthod Dentofacial Orthop 1995;107:129-35. Anderson J, Joondeph D, Turpin D. A cephalometric study of profile changes in orthodontically treated cases ten years out of retention. Angle Orthod 1973;43:324-36. Riedel R. An analysis of dentofacial relationships. Am J Orthod 1957;43:103-19. Koch R, Gonzales A, Witt E. Profile and soft-tissue changes during and after orthodontic treatment. Eur J Orthod 1979;1:193-9. Katsaros C, Ripplinger B, Hogel A, Berg R. The influence of extraction and nonextraction orthodontic treatment on the soft-tissue profile. J Orofac Orthop 1996;57:354-65. Burstone C. The integumental profile. Am J Orthod 1958;44:1-25. Subtelny J. The soft tissue profile: growth and treatment changes. Angle Orthod 1961;31:105-22. Bishara S, Cummons D, Zaher A. Treatment and posttreatment changes in patients with Class II Division 1 malocclusion, after extraction and nonextraction treatment. Am J Orthod Dentofacial Orthop 1997;111:18-27. Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am J Orthod Dentofacial Orthop 1994;106:175-86. El-Mangoury N. Orthodontic relapse in subjects in varying degrees of anterior and vertical dysplasia. Am J Orthod 1979;75:548-61. Johnson K. Cases six years post-retention. Angle Orthod 1977;47:210-21. Ricketts R. A four step analysis to distinguish orthodontic changes from natural growth. J Clin Orthod 1975;4:208-28. Cook AH, Sellke TA, BeGole EA. The variability and reliability of two maxillary and mandibular superimposition techniques, Part II. Am J Orthod Dentofacial Orthop 1994;106:463-71. Bondevik O. Changes in occlusion between 23 and 34 years. Angle Orthod 1998;68:75-80. Carter G, McNamara J. Longitudinal dental arch changes in adults. Am J Orthod Dentofacial Orthop 1998;114:88-99. Bishara S, Jakobsen J, Treder J, Nowak A. Arch width changes from 6 weeks to 45 years of age. Am J Orthod Dentofacial Orthop 1997;111:401-9. Baumrind S, Boyd RL, Maxwell R. The decision to extract: Part 1, interclinician agreement. Am J Orthod Dentofacial Orthop 1996;109:297-309. De La Cruz A, Sampson P, Little R, Artun J, Shapiro P. Long-term changes in arch form after orthodontic treatment and retention. Am J Orthod Dentofacial Orthop 1995;107:518-30.