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BJÖRN U. ZACHRISSON
Q
OSLO, NORWAY
358
A Commonly used premolar extraction pattern
When the treatment plan calls for maxillary and/or mandibular premolar extrac-
tions, it seems that many more orthodontists prefer to extract the first rather than
the second premolars.2 In a recent (2002) survey in the US, the dominant extrac-
tion pattern was the maxillary and mandibular first premolars.2 The next most
common pattern was extraction of the maxillary first premolars, with no extraction
in the mandible. The removal of the maxillary first and the mandibular second pre-
molars was the preferred pattern in only 7.5% of the extraction cases, and the
a b c
d e
Fig 1 Desirable incisor positioning and harmonious facial profile in young male ortho-
dontic patient with retraction of the incisors after mandibular second premolar extrac-
tion. Prolonged retention using gold-coated 0.030-inch lingual retainer bonded to f
canines only.
a b c
Fig 2 Finished transfer case where the extraction of both mandibular first premolars has resulted in larger-than-intended interin-
cisal angle (a). The undertorque may increase the likelihood for vertical relapse of the deep overbite. Safer alternative (b,c) with
extraction of mandibular second premolars in case with moderate crowding (b). Simple control of anchorage and space closure
using elastomeric chain and Class II elastics on straight mandibular archwire (c).
maxillary and mandibular second premolars in 6%. These numbers have remained remark-
ably similar for the past 10 years, or more.2 By tradition, an obvious reason for selecting
the mandibular first rather than the second premolars for extraction is their generally
poorer morphology—commonly a smaller tooth with a diminutive lingual cusp compared to
the second premolar. However, when the extraction decisions are made, it is my opinion
that the mandibular incisor position in space after treatment, and the predicted profile
changes with different extraction alternatives, should be regarded as more important fac-
tors than the tooth morphology and the contact point relationships between the first molar
and the neighboring premolar (Fig 1). Tooth morphology can, if necessary, be improved
with new minimally invasive prosthetic enamel bonding techniques, whereas excessive
incisor retroclination (Fig 2a) and accentuation of undesirable profile characteristics as a
result of the orthodontic treatment (Fig 3) may produce irreparable damage to the patient.
359
Fig 3 Undesirable flattening of facial
profiles following excessive retroclination
after mandibular first premolar extraction
in 2 young patients.
a b
c d
360
Fig 4 Vicious cycle of excessive retraction.
Extraction of mandibular first premolars
Vertical relapse
It should be pointed out that orthodontic treatment with extraction of mandibular pre-
molars need not always cause mandibular incisor retraction. Mandibular incisor proclina-
tion may result from labial movement of these teeth during alignment if the mandibular
canines were buccally positioned, from prolonged use of Class II traction, or if the amount
of mandibular arch crowding exceeds the extraction spaces.3,4
Prediction of profile changes with extractions of mandibular second versus first premolars
Although it may be difficult to make accurate soft tissue profile predictions in individual
cases, we still have to try to foresee what are pleasing and harmonious soft-tissue
changes with the orthodontic corrections (see Figs 1 and 7), as well as those which are not
(Fig 3). In my opinion, the most useful and adequately detailed advice in this regard comes
from Holdaway’s soft-tissue analysis and recommendations.1 This implies that the before-
treatment soft tissue thickness at point A should be used as a guide. If it is within the nor-
mal range (14 to 16 mm) in adolescents, the upper lip will follow the maxillary incisor in a
one-to-one ratio once the lip strain is eliminated. However, if the tissue at point A is very
thin (9 to 10 mm), the lip may follow the incisor immediately and still retain the taper.
Adult lips may react similarly to that of thin lips in adolescent patients. On the other hand,
if the soft tissue at point A is very thick (18 to 20 mm) at the start of orthodontic treat-
ment, the lip may not follow the incisor movement at all.
361
a b
c d e
Fig 5 With relapse of deep overbite, incisal edges of mandibular incisors occlude against labiolingually thicker portion of maxillary
incisors and canines (a to d). Small pieces of wire placed where 6 mandibular teeth occlude on maxillary cast, with various
degrees of overbite relapse (e). Note dramatic difference in length of wires (f) when stretched and measured (reprinted by permis-
sion of B.F. Swain). [Author: Were these actually printed somewhere, or are you just giving him credit (the reference was
personal communication)]
362
a b c
d e f
Fig 6 Mesial movement of mandibular second premolars with coil springs against the first molars after extraction of first premo-
lars. When the second premolars contact the canine, the anterior anchorage is reinforced and the situation is similar to that when
the second premolars have been extracted.
363
a b c
d e f
h i
Fig 7 Mandibular second premolar extraction case in male adolescent patient. The first molars were moved mesially to contact
the first premolars, using coil springs against the second molars (a to d). Next, the second molars were moved mesially with elas-
tomeric chain (d,e). Class II elastics to the first molars supported the anterior anchorage (e). Note the intraoral results (f,g) and
good facial appearance after treatment (h,i).
Clinical implications
1. When mandibular premolar extractions are necessary in an orthodontic treatment plan,
and maintenance of the pretreatment mandibular incisor position in space is desired,
the second premolars are often a better and safer choice than the first premolars.
Orthodontic treatment then becomes easier and more predictable with regard to
anchorage control and achievement of proper anterior torque, and undesired flattening
of the facial profile is more easily avoided.
2. If the mandibular first premolars are extracted, and incisor retraction is unwanted, it may
be useful to move the second premolar into contact with the canine as the first phase of
treatment, to avoid harmful effects on mandibular incisor position and facial profile.
3. To correct and maintain the correction of an excessive overbite, the orthodontist should
analyze which teeth are overerupted, intrude such teeth and establish an optimal maxil-
lary incisor to upper and lower lip relationship, and secure an adequate interincisal
angle. The mechanical means may include selecting proper bracket torque, bending
additional torque into rectangular archwires, and, if necessary, using auxiliary torquing
springs to deliver extra lingual root torque.
4. The relationship between vertical anterior relapse and increased mandibular incisor
crowding should be known and respected.
364
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