The effect of premolar extractions on tooth-size

discrepancy
Pinar Saatqi, DDS, MS," and Filiz Yukay, DDS, MS, PhD b
Ankara, Turkey

The purpose of this study is to investigate whether the extraction of four premolars as a
requirement of orthodontic therapy is a factor in the creation of tooth size discrepancies, and to
determine whether any tooth extraction combinations create more severe discrepancies. The study
is carried out on the pretreatment dental casts of 50 patients with malocclusions. The dental casts
were selected according to the main criteria. No tooth-size discrepancy between the mandibular
and maxillary dental arches should exist before treatment. Pretreatment mesiodistal dimensions of
mandibular and maxillary teeth were measured, recorded on a computer program, and subjected to
Bolton's analysis. Hypothetical tooth extractions were performed on each patient by the following
combinations: all first premolars, all second premolars, upper first and lower second premolars, and
upper second and lower first premolars. The resultant measurements were again subjected to
Bolton's analysis to see whether a tooth-size discrepancy had been created. The results were
evaluated statistically by the use of paired samples t test. The difference between the pretreatment
and postextraction Bolton values was found statistically significant for the first premolar extraction
and insignificant for the others. The removal of the four first premolars created the most severe
tooth-size discrepancy, whereas the extraction of all four second premolars created fewer
discrepancies and the smallest range in the size of discrepancies. The results of this study indicate
a new point of view to the question of which teeth to extract when evaluated for tooth size aspect
only. (Am J Orthod Dentofac Orthop 1997;111:428-34.)

Ware faced with almost daily progress
in the field of clinical orthodontics and the advances
in the diagnostic phase of treatment have also been
plentiful, but study models are still a vital diagnostic
aid. On a dental cast, we can measure "tooth size,"
specifically the mesiodistal widths of the teeth that
are very important in reconstructing the denture?
Model analysis for treatment planning includes two
major requirements of equal importance: One is an
assessment of possibilities of tooth movement, and
the other is a prognosis of denture stability after
treatment. 2
The development of the tooth-size analysis ra-
tios, which are to be the basis of this investigation,
was presented by Wayne Bolton in 1958. 3 He hoped
that tooth-size ratios could be helpful in treatment
planning of orthodontic cases and also in determin-
Ing the functional and esthetic outcome of a given
case, without the use of a diagnostic set-up. Since
that time, his tooth-size ratios have been applied to
many clinical orthodontic cases.
From the Department of Orthodontics, Hacettepe University Faculty of
Dentistry.
~Research Assistant.
bProfessor.
Reprint requests to: Dr. Pinar Saatqi, Iran Cad. 49/9, 06700 Gaziosman-
pasa, Ankara, Turkey.
Copyright 9 1997 by the American Association of Orthodontists.
0889-5406/97/$5.00 + 0 8/1/~i3857
428
Bolton 3 measured the mesiodistal widths of the
teeth from first molar to first molar in 55 patients
with excellent occlusions. He found that when the 12
maxillary teeth were compared with the 12 mandib-
ular teeth in the following ratio a standard deviation
resulted.
sum of the mandibular "12" width
• 100 = X%
sum of the maxillary "12" width
The mean was 91.3% and the standard deviation
was 1.91%. In comparing the six anterior teeth in a
similar manner, equally significant findings were
obtained. With this information, an analysis was
devised to detect tooth-size discrepancies. If a dis-
crepancy was found to exist, the ratios could be used
to determine how large it was. The measurements
are easily and quickly made, making the analysis a
practical diagnostic tool.
The purpose of orthodontic diagnosis and treat-
ment planning is to determine the best possible func-
tional and esthetic results for the patient at the end of
treatment. In certain instances, when the orthodontic
appliances are removed, the patient may have spaces
between the teeth, an excessive overjet and an in-
creased overbite.4-6 These deviations from an ideal
occlusion may be due to tooth-size discrepancy be-
tween the maxillary and mandibular dental arches.
Since the beginning of orthodontics, mechanical ther-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 111, No. 4
apy has been used to create space for crowded teeth.
Space has been created in three ways: by expansion of
the dental arch, by lengthening of the dental arch, and
by extraction of teeth or any combination of the three.
When a malocclusion requires extraction, tooth-size
differences and spacings are often seen at the end of
treatment. That is why problems associated with tooth-
size differences have been recognized for many years.
Many investigators have expressed the opinion that
removal of premolars is responsible for creating a
tooth-size discrepancy in some cases, but none of them
have reported on the percentage of cases in which this
occurs. 7-12 Also, the publications do not reveal an
analysis specifically designed for the case requiring the
extraction of four premolars.
Black 13 conducted one of the first investigations
to be made in the field of tooth size. Large numbers
of human teeth were measured and tables of mean
figures were established for each tooth in the dental
arch.
Neff8,9 developed an "anterior coefficient" to be
used as a guide to the finished relationship of the
anterior segments.
Steadman 1~ developed a method of predeter-
mining the overbite and overjet relationship.
Rees 11 found that mesiodistal widths of the
maxillary teeth exceeded those of the mandible, and
believed that the discrepancies could be reduced by
stripping, extraction, or placing crowns.
Lundstr6m ~z showed a large biologic dispersion
in the tooth width ratio, and said it was great enough
to have an impact on the final tooth position, teeth
alignment, and overbite and overjet relationships in
a large number of patients.
Ballard 14 obtained the dimensions of teeth from
the world's largest manufacturer of artificial teeth
and found that the mesiodistal widths of the six
mandibular anterior teeth were 75% of the mesio-
distal widths of the six maxillary anterior teeth. He
then advocated judicious stripping of the mandibu-
lar anterior segment to compensate for the tooth-
size discrepancy.
Peck and Peck 15 found statistically significant
differences in both the mesiodistal (MD) and facio-
lingual (FL) dimensions of mandibular incisors,
between perfectly aligned and control populations
of untreated females. Combining these measures
into an index (MD/FL • 100), they formulated ideal
size ranges required for central and lateral incisors
to be well aligned. They recommended MD reduc-
tion of incisors to place them within this range and
prevent further crowding.
However, Gilmore and Little 16 found that,
although there was a tendency for incisors with a
greater mesiodistal dimension to be associated
with crowding, the association was so weak that
reduction of the widths of incisors to fit a specific
Saatqi and Yukay 429
range cannot be expected to produce a stable
alignment.
Recently, Crosby and Alexander ~7 found no dif-
ference in the incidence of tooth-size discrepancies
in different malocclusion groups but showed that a
large percentage of patients had mesiodistal tooth-
size discrepancies at pretreatment Bolton analysis.
They suggested that the Bolton tooth-size analysis
was an important diagnostic tool and should be used
for every orthodontic patient before initiation of
treatment.
One of the major diagnostic decisions that is
required in orthodontic practice is whether to ex-
tract some permanent teeth to properly align the
others. Much has been written for and against the
removal of teeth for the correction of malocclusions.
The trend today in orthodontics appears to be in
favor of the removal of very carefully selected teeth
in the correction of certain unavoidable cases. In
certain types of malocclusions, after a careful study
of the patient, photographs, x-ray films, and casts, it
becomes apparent from case analysis that dental
units must be removed if stable dentures are finally
to be obtained after orthodontic treatment. The
question "which teeth?" should next occupy our
attention.
The purposes of this study are (1) to investigate
whether the extraction of four premolars as a re-
quirement of orthodontic therapy is a factor in the
creation of tooth-size discrepancies, (2) to deter-
mine whether any tooth extraction combinations
create more severe discrepancies, and finally (3) to
find a simple, clinically suitable method of localizing
tooth-size disharmonies in four premolar extraction
cases.
MATERIALS AND METHODS
The measurements used in this study were made from
pretreatment plaster models of 50 patients with malocclu-
sions. No attempt was made to select patients on the basis
of gender, race, or classification of malocclusion. In all
selected patients, all the permanent teeth were sufficiently
erupted to allow measurement of their widest mesiodistal
dimensions. Patients with interproximal lesions or resto-
rations were not used. The major criteria for each patient
studied was that, with the Bolton's analysis, a tooth-size
discrepancy did not exist between the maxillary and
mandibular teeth in the pretreatment models. To select
each set of models, the teeth were measured with a fine
point Boley gauge. Bolton3 found that the mean overall
ratio in patients with no tooth-size discrepancy is 91.3%
and the standard deviation from this mean is _+1.91%.
Therefore any patient with an overall ratio of 89.4% and
93.2% was considered to have an acceptable relationship
between the dental arches. An attempt was made to select
patients who showed an overall ratio very near the mean
value of 91.3%. About 200 patients were examined to
430 Saatgi and Yukay
provide the 50 patients accepted for this study. After these
50 patients were selected, pretreatment mesiodistal di-
mensions of mandibular and maxillary teeth were re-
corded on a special computer program written for this
study by Dr. Aksoy and Bolton's tooth-size analysis was
performed and pretreatment Bolton values were calcu-
lated. Four premolars were then hypothetically removed
in four different combinations from each case. These
combinations were (1) removal of all first premolars; (2)
removal of all second premolars; (3) removal of upper first
and lower second premolars; and (4) removal of upper
second and lower first premolars.
The hypothetical extraction was accomplished by sub-
stituting "zero" to the place of the corresponding premo-
lars that were removed. The resultant measurements were
again subjected to Bolton's analysis to see whether a
tooth-size discrepancy had been created, by using a sec-
ond computer program for every extraction combination
one by one.
Bolton is presented another article dealing with the
clinical application of his tooth-size analysis. He reported
that the overall ratio should not be used as a specific guide
to the predicted occlusion after the removal of four
premolars. He explained that a ratio set-up between arcs
of unequal length (such as dental arches) would not
remain constant when segments (premolars) of approxi-
mately equal size were removed from each arch. Bolton
further stated that after the extraction of four premolars,
patients in whom no tooth-size discrepancy existed would
have an overall ratio that fell in a range from 87% to 89%
with a mean value of 88%. We used this value for the
second computer program.
For example, mesiodistal widths Of the maxillary and
mandibular teeth of our first patient were measured,
recorded to the computer, and subjected to Bolton's
analysis:
mand. 12 ?3.4
max. 12 ~ ~x100= 91.12%
Bolton's overall ratio for this malocclusion before
treatment was 91.12%, which is very close to the ideal
mean 91.3%, and the Bolton value was found to be 0.2
mm excess in the maxilla. The maxillary and mandibular
first premolars were extracted hypothetically by recording
"0" to the place of the corresponding premolars that were
removed, with the second computer program and Bolton's
analysis repeated. In this case, if we extract upper first and
lower first premolars,
mand. 10 78.40
x 100 = 90.53%
max. 10 86.60
Bolton value (10 teeth) = 2.19 mm excess in the mandible.
The same procedure was carried out for the three
other combinations of premolar removal on this patient
and these results were obtained. If we extract upper
second and lower second premolars,
American Journal of Orthodontics and DentofacialOrthopedics
April 1997
mand. 10 77.70
• 100 = 88.10%
max. 10 - 88.20
Bolton value (10) = 0.08 mm excess in the mandible. I f we
extract upper first and lower second premolars,
mand. 10 77.70
--• 100 = 89,72%
max, 10 - 86.60
Bolton value (10) = 1.49 mm excess in the mandible. If we
extract upper second and lower first premolars,
mand. 10 78.40
- - • 100 = 88.89%
max. 10 - 88.20
Bolton value (10) = 0.78 mm excess in the mandible.
The results show that, although there were no tooth-
size discrepancies before treatment, extraction of all first
premolars and upper first and lower second premolars
created discrepancies with the overall ratios that were
outside the range of 87.0% to 89.0%, described by
Bolton. 3 On the contrary, extraction of all second premo-
lars and upper second and lower first premolars did not
create tooth-size discrepancies with the overall ratios that
were in the range of 87.0% to 89.0%. W h e n the Bolton
values were evaluated, the Bolton value was 0.2 mm
before treatment and it was raised to 2.19 mm when all
first premolars were extracted and reduced to 0.08 mm
when all second premolars were extracted. In this case,
extraction of all first premolars created the highest tooth-
size discrepancy between the dental arches.
The pretreatment and postextraction tooth-size ratios
and Bolton values were evaluated statistically by the use of
paired samples t test.
RESULTS AND DISCUSSION
At least one combination of premolar extraction
c r e a t e d a clinically significant t o o t h - s i z e d i s c r e p a n c y
in 32 o f t h e 50 p a t i e n t s studied.
The pretreatment and postextraction mean
B o l t o n values c a n b e s e e n in T a b l e I a n d Fig. 1.
A l t h o u g h t h e p r e t r e a t m e n t m e a n B o l t o n v a l u e was
0.885 ram, t h e r e m o v a l o f all s e c o n d p r e m o l a r s
r e d u c e d it to 0.840, a n d t h e r e m o v a l o f all first
p r e m o l a r s r a i s e d it to 1.252 ram.
T h e b a r g r a p h in Fig. 2 shows t h e n u m b e r o f
d i s c r e p a n c i e s c r e a t e d by e a c h c o m b i n a t i o n o f t o o t h
removal. T h e e x t r a c t i o n o f all first p r e m o l a r s cre-
a t e d d i s c r e p a n c i e s in 31 o f the 50 p a t i e n t s studied,
whereas extraction of four second premolars created
in only 17 o f t h e 50 patients. T h e values for t h e o t h e r
c o m b i n a t i o n s a r e shown in Fig. 2.
The distribution of pretreatment and postextrac-
tion B o l t o n v a l u e s in t h e maxilla a n d t h e m a n d i b l e
a r e shown in Fig. 3. A l t h o u g h t h e B o l t o n v a l u e s o f
50 p a t i e n t s w e r e in t h e maxilla for 36 a n d in t h e
m a n d i b l e for 14 o f t h e p a t i e n t s b e f o r e t r e a t m e n t ,
t h e y t u r n e d o u t to b e 3 in t h e m a x i l l a , 47 in t h e
American Journal of Orthodontics and Dentofacial Orthopedics Saatqi and Yukay 431
Volume 111, No. 4

BoRon values
1,6 -
1,4 1252
1175
1.2 004
1 0 885

0,8 I'
0,6
0,4
0,2
0
4 4 5 5 4 4 5 5
44 5 5 55 4 4

Tooth extraction type 9 BEFORE 9 AFTER

Fig. 1. Bolton values before and after tooth extraction.

Number of patients
4o
3~

30!

20

lO
i
n=50
4i4 5r5 414 5 5
44 5i5 5i5 4 4
Tooth extraction type

Fig. 2. Tooth-size discrepancies created by the removal of premolars.

Table I. M e a n B o l t o n v a l u e s b e f o r e a n d a f t e r t o o t h e x t r a c t i o n s
! I
Before [ After first [ After secoml After upper first, tower After upper second,
extractions 1 premolars l premolars second premolars lower first premolars

Minimum 0.040 0,010 0.040 0.110 0.070

Maximum 2.010 3,720 2.580 3.800 2.990
Mean 0.885 1,252 0.840 1.175 1.004
Standard deviation 0.595 0,916 0.769 0.924 0.715
Standard error 0.084 0,130 0.109 0.131 0.101

N= 50.

mandible after the extraction of all first premolars, mesiodistal dimension. It appeared that, because
and 13 in the maxilla, 37 in the mandible after the most discrepancies created by extraction occurred as
extraction of all second premolars. In this study, as a mandibular excess, removal of the mandibular
in the studies of Bolton 3,t8 and Ballard, 19 the man- second premolars, which usually had wider mesio-
dibular second premolar showed the largest mean distal dimensions, was likely to create discrepancies
432 Saatfi and Yukay American Journal of Orthodontics and Dentofacial Orthopedics
April 1997

Number of patients
60
4i 4 .5i. 5_ 41 4 55j5
50 "4~!4- llm47 5i 5 5~5~ I~i48 --414
40 i 36 n 3637 36 i 36 37
30
20 i
101
0L~
LlULlU .......................
Tooth extraction type

i J MAXILLA (before) 9 MANDIBLE (before)

, [] MAXILLA (after) 9 MANDIBLE (after) j

Fig. 3. Bolton values in maxilla and mandible, before and after tooth extraction.

NUMBER OF PATIENTS

25

20

15
10
UPPER 5 LOWER 4
5 PPER 4 LOWER 5
>ER 5 LOWER 5
0 R 4 LOWER 4
0-1 1.1-2 2.1-3 3.1-4
DISCREPANCY (mm)

Fig. 4. Frequency and magnitude of Bolton values created by removal of different

combinations of premolars.

of a smaller size than the mandibular first premo-
lars.
The bar graph in Fig. 4 shows the frequency and
magnitude of discrepancies in different millimeter
ranges for different combinations of premolar ex-
tractions. The removal of upper and lower second
premolars created discrepancies of a smaller size
than the discrepancies created by other three com-
binations. Also, removal of all first premolars cre-
ated more frequent and greater' discrepancies than
the others.
The results of paired samples t test, comparing
the difference between Bolton values that were
measured before treatment and after the removal
of premolars, are shown in Table II, A through D.
The difference between the pretreatment Bolton
value and after the removal of first premolars was
found statistically significant and insignificant for
the other three combinations. The extraction of
all first premolars created more severe discrepan-
cies (Table II, A). Conversely the extraction of all
second premolars reduced the discrepancies that
had existed before treatment (Table II, B). It was
also noted in this study that, if we extracted
premolars of equal mesiodistal dimensions from
upper and lower dental arches, more severe and
frequent tooth-size discrepancies were created
when compared with the removal of greater man-
American Journal of Orthodontics and Dentofacial Orthopedics Saatr and Yukay
Volume 111, No. 4

T a b l e II. B o l t o n values b e f o r e and after tooth extractions

A, All first p r e m o l a r s

Minimum Maximum X ] SD t
Before 0.040 2.010 0.885 0.595 2.238 p < 0.05
After 0.010 3.720 1.252 0.916

B, All s e c o n d p r e m o l a r s

Minimum [ Maximum X I SD t
Before 0.040 2.010 0.885 0.595 0.361 p > 0.05
After 0.040 2.580 0.840 0.769

C, Upper first, l o w e r s e c o n d p r e m o l a r s

] Minimum ] Maximum I x I so I
Before 0.040 2.010 0.885 0.595 1.962 p > 0.05
After 0.110 3.800 1.175 0.924

D, U p p e r s e c o n d , l o w e r first p r e m o l a r s

Minimum Maximum [ X ] SD t p
Before 0.040 2.010 0.885 0.595 0.906 p > 0.05
After 0.070 2.990 1.004 0.715

dibular premolars. Therefore this result is in
agreement with the opinion expressed by Bolton
that the removal of mandibular second premolars
often creates the potential for a better occlusion
than the removal of the first premolars, as the
mandibular molars are allowed more mesial
movement. But Bolton also cautioned, as we do,
that his statement should not be interpreted as a
broad recommendation for extraction of mandib-
ular second premolars. 3,1s
The results obtained in this study suggest a
new point of view to the question of which teeth to
extract when evaluated from a tooth-size discrep-
ancy standpoint only. The question of the reduc-
tion of tooth structure as a treatment procedure in
orthodontics has always been a controversial one.
Controversy centers on how far we should go and
what the dividing line between extraction and
nonextraction is. The decision to extract must be
preceeded by a great deal of thought and study.
Claridge 5 designed the only analysis of fully
erupted dentitions that could accurately assess the
overjet and spacing that would be present at the
completion of treatment of a case requiring tooth
extraction. He emphasized that, with the small
standard deviation and the high predictability, his
analysis was a reliable clinical aid compared with
Bolton's analysis, which was also more time-
consuming.
CONCLUSION
We accordingly conclude that clinicians should always
remember to look on each patient individually and be
aware of other factors in determining what teeth, if any,
should be removed and use these findings only as one
factor to be considered together with many others.
We acknowledge Dr. Ata Omit Aksoy for his helpful
suggestions during the preparation of this investigation
and for the invaluable computer program written for this
study.
REFERENCES
1. Currier JH. A computerized geometric analysis of human dental arch form. Am J
Orthod 1969;56:164-79.
2. Howes AE. Model analysis for treatment planning: a portion of a symposium on
case analysis and treatment planning. Am J Orthod 1952;38:183-207.
3. Bohon WA. Disharmor~yin tooth size and its relation to the analysis and treatment
of malocclusion.Angle Orthod 1958:28(3):1 I3-30.
4. Bishara SE. Management of diastemas in orthodontics. Am J Orthod 1972;61:55-
63.
5. Claridge D. Evaluating tooth size in premolar-extraction cases. Am J Orthod
1973;64:457-68.
6. Van Der Linden FDGM, Boersma H. Diagnosis and treatment planning in
denlofacial orthopedics. London: Quintessence Publishing Co. Ltd., 1987:117-58.
7. Nanee HN. The limitations of orthodontic treatment: I1, diagnosis and treatment
in the permanent dentition. Am J Orthod Oral Surg 1947;33:253-301.
434 Saat~i and Yukay American Journal of Orthodontics and Dentofacial Orthopedics
April 1997

8. Neff:CW. Tai)ored occlusion with the anterior coefficient. Am J Orthod 1949;35:309-
14.
9. Neff CW. The size relationship between the maxillary and mandibular anterior
segments of the dental arch. Angle Orthod 1957;27:138-47.
10. Steadman SR. The relation of upper antet'ior teeth to lower anterior teeth as present
on plaster models of a group of acceptable occlusions.Angle Orthod 1952;22:91-7.
11. Rees DJ. A method for assessing the proportional relation of apical bases and
contact diameters of the teeth. Am J Orthod 1953;39:695-707.
12. Lundstr6m A. Intermaxillary tooth width ratio and tooth alignment and occlusion.
Acta Odontol Scand 1954;12:265-92.
13. Black GV. Descriptive anatomy of the human teeth. 4th ed. Philadelphia: SS White
Dental, 1902.
14. Ballard ML A fifth column within normal dental occlusions. Am J Orthod
1956;42:116-24.
15. Peck S, Peck H. Crown dimensions and mandibular incisor alignment. Angle
Orthod 1972;42:/48-53.
16. Gilmore CA, Little RM. Mandibular incisor dimensions and crowding. Am J
Orthod 1984;86:493-502.
17. Crosby DR, Alexander CG. The occurrence of tooth-size discrepancies among
different malocclusion groups. Am J" Orthod Dentofac Orthop 1989;95:457-61.
18. Bolton WA. The clinical application of a tooth-size analysis. Am J Orthod
1962;48:504-29.
19. BallardML, Wylie WL. Mixed dentition case analysis, estimating size of unerupted
permanent teeth. Am J Orthod 1947;33:754-60.

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