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ORIGINAL ARTICLE

Extraction of maxillary first permanent molars


in patients with Class II Division 1 malocclusion
Mattijs J. P. Stalpers,a Johan W. Booij,b Ewald M. Bronkhorst,c Anne Marie Kuijpers-Jagtman,d
and Christos Katsarose
Nijmegen and Gorinchem, the Netherlands

Introduction: Our objectives were to assess treatment outcomes in Class II Division 1 patients who were
treated orthodontically with extraction of the maxillary first permanent molars and to describe the changes
in their facial profiles. Methods: This was a prospective, longitudinal, 1-group outcome analysis in a private
practice, with outcome evaluation by independent observers at an academic clinic. One hundred consec-
utively treated patients were enrolled prospectively and treated by 1 orthodontist. The inclusion criteria were
white, Class II Division 1, sagittal overjet of ⱖ4 mm, extraction of maxillary first permanent molars, no missing
teeth or agenesis, maxillary third molars present, and 1-stage full fixed appliance treatment. Standardized
lateral cephalometric radiographs were made before and after active treatment. Occlusal outcome was
scored on dental casts by comparing pretreatment and posttreatment casts with the peer assessment rating
(PAR) index. Backward regression analysis was used to explain the soft-tissue changes on the basis of dental
changes and the soft-tissue characteristics. Results: The mean reduction in weighted PAR score was 89.9%
(SD, 0.9). During treatment, the lower lip retruded 1.6 mm (SD, 1.7) relative to the esthetic line. The nasolabial
angle became 2.1° (SD, 7.0) more obtuse during treatment. Overjet reduction and initial upper lip thickness
could explain 15% of the variation in upper lip position. The changes in the position of the mandibular incisor
relative to the Point A-pogonion line and initial lower lip thickness could explain 23% of the variation of lower
lip position. Conclusions: Orthodontic treatment involving extraction of the maxillary first permanent molars
has a good treatment outcome. Extraction of the maxillary first permanent molars has only a small effect on
the soft-tissue profile. (Am J Orthod Dentofacial Orthop 2007;132:316-23)

T
he Class II relationship is the most prevalent with a favorable growth pattern. For a postpubertal
subclassification of malocclusion. Recognizing patient seeking treatment, surgical correction of the jaw
the limitations of this description, epidemiolo- abnormality can be an option. The third option is
gists have formulated indexes and scales for use in orthodontic treatment combined with extraction of
public health studies. The results of these surveys teeth. In case of crowding in both arches, extraction of
suggest that 15% to 22% of American teenagers have 4 teeth is often indicated. In case of overjet and a good
an overjet of 5 mm or greater.1 For those seeking or potentially good mandibular arch, extractions can be
orthodontic treatment to have the overjet corrected, limited to the maxillary arch only. Space analysis of the
there are generally 3 treatment options. Clinical and mandibular arch involves factors such as crowding or
anamnestic findings are key factors in narrowing the spacing, the curve of Spee, and the position of the
choices. Growth modification, with either headgear or mandibular incisors.2 Within reason, these incisors can
activator, might be suggested for a prepubertal patient be left slightly proclined. This compensated position is
a
Orthodontist, Department of Orthodontics and Oral Biology, Radboud Uni- presumably stable, provides extra arch space, and
versity Nijmegen Medical Center, Nijmegen, the Netherlands. reduces the amount of retraction needed for the maxil-
b
Private practice, Gorinchem, the Netherlands.
c
Biostatistician, Department of Preventive and Curative Dentistry, Radboud
lary incisors. This in turn can provide an improved
University Nijmegen Medical Center, Nijmegen, the Netherlands. facial profile in many Class II patients.3
d
Professor and chair, Department of Orthodontics and Oral Biology, Radboud When the clinician decides to extract teeth, the next
University Nijmegen Medical Center, Nijmegen, the Netherlands.
e
Professor, Department of Orthodontics and Oral Biology, Radboud University
question is which teeth are to be extracted. The most
Nijmegen Medical Center, Nijmegen, the Netherlands. obvious choice might be to extract the first or second
Reprint requests to: Christos Katsaros, Radboud University Nijmegen premolars. In certain cases, extraction of the first perma-
Medical Center, Department of Orthodontics and Oral Biology, 117
Tandheelkunde, PO Box 9101, 6500 HB Nijmegen, the Netherlands; e-mail,
nent molars can be preferred. In addition to extracting the
c.katsaros@dent.umcn.nl. first permanent molars in a systematic othodontic treat-
Submitted, June 2005; revised and accepted, January 2006. ment approach, there are certain objective indications for
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists. first molar extractions. These might be extensive caries
doi:10.1016/j.ajodo.2006.01.034 lesions, large fillings, endodontic or periodontal problems,
316
American Journal of Orthodontics and Dentofacial Orthopedics Stalpers et al 317
Volume 132, Number 3

or hypoplastic enamel. A dogma in orthodontics is that interdigitation was reached in 6 months. At this point,
extraction in the posterior part of the dental arch has a the maxillary premolars were bonded. In the end phase
bite-closing effect that would be beneficial for high-angle of treatment, adjustments were made in the archwires
patients and, on the other hand, detrimental in low-angle for detailed finishing. In most cases, retention was with
patients.4 Another extensively debated belief is that ex- fixed retainers. To prevent overeruption of the mandib-
traction in the molar area would have less influence on the ular second molars, local retention wires were bonded
facial profile than premolar extractions. In a study of between the first and second molars; the wires were
cephalometric changes in a group of borderline extraction removed when the maxillary third molars were in
patients treated with or without premolar extractions, it occlusal contact with the mandibular second molars.
was observed that the facial profiles of the extraction Standardized lateral cephalometric radiographs
group were, on average, 2 mm flatter than the profiles of were made before (T1) and after (T2) active treatment.
the nonextraction patients.5 Katsaros et al6 found, in a The radiographs were scanned on an 8-bit scanner
study on extraction vs nonextraction treatment, high vari- (Linotype-Hell, Eschborn, Germany). Tracing of the
ability in soft-tissue changes, which were unpredictable films was done in Viewbox (dHal Orthodontic Soft-
for an individual patient.6 In the orthodontic literature, ware, Athens, Greece), a software program for cepha-
there are few data concerning the extraction of first molars lometric analysis. All tracings were corrected to life
as part of orthodontic treatment. Patients and methods size. Skeletal, dental, and soft-tissue cephalometric
have been described, but prospectively collected data are landmarks were used. The cephalometric landmarks
absent.7,8 and reference lines are illustrated in Figure 1.
The purposes of our study were to assess treatment To evaluate the influence of treatment on different
outcomes in Class II Division 1 patients treated with vertical facial types, the sample was divided into 3
extraction of the maxillary first permanent molars and groups: horizontal (ANS-Me/N-Me ⱕ56%; n ⫽ 18),
to describe the changes in their facial profiles. normal (56% ⬍ANS-Me/N-Me ⬍58%; n ⫽ 21), and
divergent (ANS-Me/N-Me ⱖ58%; n ⫽ 61).9
MATERIAL AND METHODS Mean tracings of the 100 patients were constructed
The sample consisted of 100 consecutively treated and superimposed. To calculate a mean tracing, the
patients (45 girls, 55 boys) who were enrolled prospec- tracings were superimposed on the anterior nasal spine
tively. The intake of patients started in 1998 and (ANS)-posterior nasal spine (PNS) line at ANS. After
finished in 2004. All patients were treated by 1 orth- all tracings had been superimposed on each other,
odontist (J.W.B.). The following inclusion criteria were Viewbox calculated the mean coordinates for each
used: white, Class II Division 1 malocclusion, sagittal cephalometric point. These mean coordinates were
overjet of ⱖ4 mm, treatment plan included extraction used to construct a new tracing, the mean tracing. This
of maxillary first permanent molars, no missing teeth or was done for T1 and T2. These mean tracings were, in
agenesis, maxillary third molars present, and 1-stage their turn, superimposed on ANS-PNS at ANS to
full fixed appliance treatment. The mean age at the start illustrate treatment effect and growth.
of treatment was 13.2 years (range, 10.5-17.2; SD, 1.4). The occlusal outcome of treatment was scored on
The maxillary second molars and the mandibular the dental casts, by comparing the casts at T1 and T2
molars were banded before the extractions. The molar with the peer assessment rating (PAR index).10 The
bands had 6-mm single 0.018-in round buccal tubes and PAR index is applied to a patient’s pretreatment and
palatal sheaths. The maxillary first molars were sepa- posttreatment dental casts. Scores are assigned to the
rated to facilitate the extractions, and, after 3 weeks, various occlusal traits that make up the malocclusion.
both arches were bonded with light wire Begg brackets. The components of the PAR index are alignment of
The maxillary premolars were not bonded in the first maxillary anterior segments, alignment of mandibular
phase of the treatment to reduce friction. The maxillary anterior segments, left buccal occlusion, right buccal
second molars were connected by a removable palatal occlusion, overjet, overbite, and center line. British
bar to increase anchorage and to correct possible weightings were used; this means that the individual
rotations and transverse malpositions. Canine retraction scores for overjet were multiplied by 6, overbite by 2,
was performed with elastics (light 5/16 in) from the and center line by 4. A score of zero indicates good
maxillary canine to the maxillary second molar, and the alignment and occlusion, and higher scores indicate
patient was instructed to replace them only once a increased levels of irregularity or malocclusion. The
week. If the maxillary second molars moved mesially difference between the pretreatment and posttreatment
too fast, the intra-arch elastics were replaced by Class II PAR scores indicates improvement as a result of
elastics. In most patients, Class I canine and premolar orthodontic intervention. Furthermore, the percentage
318 Stalpers et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2007

ⱖ30% reduction), and greatly improved (generally a


reduction of 22 weighted PAR points or more).11
To assess the method error, the cephalograms of 20
patients and the dental casts of 50 patients were
measured by a second orthodontist. For the assessment
of interobserver error, the duplicate measurement error
was calculated with Dahlberg’s formula.12 Paired t tests
were used to assess systematic differences between the
2 observers for the cephalometric variables.

Statistical analysis
Differences between the cephalometric variables
and the PAR score before and after treatment were
analyzed by using paired t tests. To evaluate the
influence of treatment on the various vertical facial
types, ANOVA was applied, followed post hoc by the
Bonferroni correction for multiple testing. T tests were
used to assess the difference in the treatment effect
between boys and girls. For only 2 of the 22 variables
tested (21 cephalometric variables and the PAR score),
a statistically significant difference between the sexes
was found: overbite and length of the nose (N-No).
Therefore, the results are presented for the complete
patient group, regardless of sex.
Multiple linear regression was used to attempt to
explain the soft-tissue changes on the basis of dental
changes. The change in the sagittal position of the
upper lip relative to the esthetic line (Ls to E-line) was
used as the dependent variable. Several independent
variables were used: change in the sagittal position of
the maxillary incisor relative to Point A-pogonion (U1
to A-Pog), change in the maxillary incisor inclination
(U1L/ANS-PNS), change in overjet, and sex. The
pretreatment thickness (Ls-U1) of the upper lip was
added as a controlling variable. To reduce the initial
model, stepwise backward regression was applied with
a threshold for the P value of .1 for removing a variable
from the model. A similar approach was used for the
lower lip: change in the sagittal position of the lower lip
relative to the esthetic line (Li to E-line) was used as a
dependent variable, and change in the sagittal position
of the mandibular incisor relative to A-Pog (L1 to
A-Pog), change in mandibular incisor inclination (L1L/
Fig 1. Cephalometric points and reference lines used in
study. ML), change in overjet, and sex were the independent
variables. Again, the pretreatment thickness of the lip
(Li-L1) was added as a controlling variable.
of improvement was calculated. This percentage also To analyze the relationship between age at start of
reflects the change relative to the pretreatment score but treatment and treatment effect on cephalometric vari-
gives a more sensitive assessment. ables, scatter plots were made to check for nonlinear
To illustrate the degree of improvement, the nomo- relationships. Without indications for a nonlinear rela-
gram was used, in which the degree of change is tionship, Pearson correlations were calculated to quan-
separated into 3 sections: worse or no different (patients tify the relationship between age and the cephalometric
with less than 30% reduction), improved (patients with variables. For the relationshipbetween the reduction in
American Journal of Orthodontics and Dentofacial Orthopedics Stalpers et al 319
Volume 132, Number 3

Table I. Results of method error analysis (first 2 col- score was 89.9% (SD, 0.9). The mean absolute reduc-
umns relate to paired t test) tion was 26.3 points (SD, 7.3) to 2.9 points (SD, 2.4) at
Mean difference Duplicate
T2. Thirteen patients had a PAR score of zero at T2; 10
between measurement was the highest PAR score at T2. There were no
Variable observers P value error patients in the “worse or no different” group, 27 were in
the “improved” group, and 73 were in the “greatly
Dental cast analysis
PAR ⫺1.595 ⬍.0001 3.297 improved” group. The nomogram is shown in Figure 2.
Cephalometric analysis For both the absolute and the relative reduction of
SNA angle (°) ⫺0.044 .357 0.194 the PAR score, no statistically significant correlation
SNB angle (°) ⫺0.047 .147 0.133 with age was found.
ANB angle (°) 0.015 .682 0.145
Just 1 cephalometric variable showed a statistically
SN/ANS-PNS (°) 0.065 .017 0.114
SN/ML (°) ⫺0.044 .176 0.133 significant correlation with age. The difference of N-No
ANS-PNS/ML (°) ⫺0.106 .006 0.165 (T2 – T1) had a negative correlation with age (r ⫽
ANS-ME/N-ME (ratio) 0.094 .443 0.495 – 0.344, P ⫽ .0%). All other cephalometric variables
U1L/ANS-PNS (°) ⫺0.032 .583 0.238 had P values above 5% for the statistical significance of
U1 to A-Pog (mm) 0.121 .002 0.167
the correlation with age. Therefore, the results are
L1L/ML (°) 0.124 .043 0.254
L1 to A-Pog (mm) 0.121 .005 0.184 presented without considering the patients’ ages.
Overbite (mm) ⫺0.018 .338 0.068 As shown in Table II, at T1, the patient group had
Overjet (mm) 0.003 .861 0.075 typical Class II Division 1 characteristics: enlarged
Nasolabial angle (°) 0.759 .358 3.351 ANB angle (mean, 5.5°), overjet (mean, 7.3 mm), and
Ls to Sn-Pog’ (mm) ⫺0.041 .657 0.375
overbite (mean, 2.9 mm). Furthermore, the maxillary
Li to Sn-Pog’ (mm) ⫺0.076 .387 0.358
Ls to E-line (mm) ⫺0.029 .658 0.268 incisors were protruded in relation to the A-Pog line. At
Li to E-line (mm) ⫺0.059 .442 0.310 T2, the ANB angle showed a significant reduction of
N-No (mm) ⫺0.144 .185 0.444 1.8° (SD, 1.5), mainly due to a reduction in the SNA
Ls-U1 (mm) 0.047 .702 0.497 angle.
Li-L1 (mm) ⫺0.206 .024 0.383
Superimposition of the mean tracings at T1 and T2
visually represents the overall treatment effect (Fig 3).
During treatment, the maxillary incisors were re-
the PAR score (both absolute and relative reductions), tracted 2.7 mm (SD, 1.9) in relation to A-Pog. The
the same procedure was followed. inclination of the maxillary and mandibular incisors
changed significantly. The maxillary incisors retro-
RESULTS clined 2.3° (SD, 6.6) on ANS-PNS, and the mandibular
The average duration of active orthodontic treat- incisors proclined 5.3° (SD, 5.0) to 103.2°(SD, 6.7) on
ment was 2.5 years (SD, 0.6). All 100 patients who mandibular line. The retraction and the retroclination of
were enrolled in the study finished treatment. The mean the maxillary incisors and the proclination of the
age at T2 was 15.7 years (SD, 1.6; range, 12.4-19.8). mandibular incisors together with growth must have
In Table I, for all variables, the results of the paired contributed to the overjet reduction of 4.8 mm (SD, 1.8)
t test comparing the 2 observers and the duplicate from 7.3 mm (SD, 1.8) at T1 to 2.5 mm (SD, 0.9) at T2.
measurement error are given. For 6 cephalometric Overbite was reduced from 2.9 mm (SD, 2.7) at T1 to
variables (SN/ANS-PNS, ANS-PNS/ML, U1 to A-Pog, 1.3 mm (SD, 0.8) at T2. These changes were all
L1L/ML, L1 to A-Pog, and Li-L1) and the PAR score, significant.
a statistically significant difference between the 2 The position of the upper lip relative to the E-line
observers was found. For angles, a maximum duplicate (Ls to E-line) was 0.77 mm (SD, 2.5) at T1. At T2, its
measurement error of 0.25° and, for distances, a max- position was 3.3 mm (SD, 2.1) behind the E-line, a
imum duplicate measurement error of 0.38 mm were change of –2.6 mm (SD, 1.7). The position of the lower
found. However, for all variables, the duplicate mea- lip relative to the E-line (Li to E-line) was ⫹0.1 mm
surement error was small compared with the standard (SD, 2.3) at T1. At T2, its position was 1.6 mm (SD,
deviations of the measurement (Table II). 2.3) behind the E-line, a change of –1.6 mm (SD, 1.7).
The descriptive statistics for the PAR score are The nasolabial angle became 2.1° (SD, 7.0) more
summarized in Table II. The average PAR score at T1 obtuse during treatment.
was 29.2 (SD, 7.3). Eighty-four of the 100 patients had In Table III, the results of the regression analysis
an initial score of ⱖ22 points; 15 was the lowest initial aiming at prediction of the soft-tissue changes by dental
score. The mean percentage reduction in weighted PAR variables are given. For the upper lip after applying
320 Stalpers et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2007

Table II. Descriptive statistics for cephalometric and dental cast measurements (P values calculated with paired t tests)
T1 T2 T2–T1

Variable Mean SD Mean SD Mean SD P value

Dental cast analysis


PAR* 29.16 7.34 2.88 2.43 ⫺26.28 7.32 ⬍.0001
PAR† 29.16 7.34 2.88 2.43 89.9% 0.9 ⬍.0001
Cephalometric analysis
Skeletal sagittal
SNA angle (°) 79.82 3.74 77.70 3.94 ⫺2.12 1.92 ⬍.0001
SNB angle (°) 74.34 3.67 73.98 3.72 ⫺0.35 1.24 .0051
ANB angle (°) 5.48 1.92 3.72 2.23 ⫺1.76 1.54 ⬍.0001
Skeletal vertical
SN/ANS-PNS (°) 7.23 3.31 7.30 3.38 0.07 1.50 .6361
SN/ML (°) 35.02 5.74 35.35 6.31 0.33 1.66 .0485
ANS-PNS/ML (°) 27.80 5.12 28.06 5.54 0.26 1.78 .1515
ANS-ME/N-ME (ratio) 58.21 2.34 58.54 2.35 0.32 1.29 .0147
Dentoalveolar
U1L/ANS-PNS (°) 110.38 5.56 108.05 5.39 ⫺2.33 6.62 .0006
U1 to A-Pog (mm) 9.03 2.41 6.30 1.86 ⫺2.72 1.88 ⬍.0001
L1L/ML (°) 97.92 6.33 103.18 6.57 5.26 4.94 ⬍.0001
L1 to A-Pog (mm) 1.66 1.99 3.82 1.86 2.15 1.63 ⬍.0001
Dental
Overbite (mm) 2.87 2.65 1.34 0.84 ⫺1.53 2.42 ⬍.0001
Overjet (mm) 7.28 1.84 2.48 0.85 ⫺4.81 1.80 ⬍.0001
Soft tissue
Nasolabial angle (°) 114.85 9.27 116.98 10.35 2.12 7.02 .0032
Ls to Sn-Pog’ (mm) 4.66 1.81 3.26 1.58 ⫺1.39 1.42 ⬍.0001
Li to Sn-Pog’ (mm) 3.44 1.98 2.63 1.91 ⫺0.80 1.46 ⬍.0001
Ls to E-line (mm) ⫺0.77 2.46 ⫺3.32 2.14 ⫺2.56 1.71 ⬍.0001
Li to E-line (mm) 0.10 2.33 ⫺1.55 2.31 ⫺1.64 1.67 ⬍.0001
N-No (mm) 48.62 3.77 51.54 4.07 2.92 2.15 ⬍.0001
Ls-U1 (mm) 11.01 2.32 13.47 2.04 2.47 1.59 ⬍.0001
Li-L1 (mm) 14.56 1.56 13.10 1.43 ⫺1.46 1.52 ⬍.0001

*Absolute difference.

Percentage improvement.

backward regression, only initial lip thickness and respectively. The difference between the vertical and
change in overjet remained in the model. For every the other 2 groups was statistically significant (P ⫽
millimeter of overjet reduction, a reduction of 0.396 .018).
mm of Ls to E-line is to be expected. For every
millimeter of upper lip thickness at T1, a 0.168-mm DISCUSSION
reduction in Ls to E-line is expected. For the lower lip, This study is the first to evaluate the quality of the
all variables except initial thickness and change in L1 to treatment results of Class II Division 1 patients treated
A-Pog were excluded from the model. For every with extraction of the maxillary first molars. To do this,
millimeter of increase in L1 to A-Pog, an increase of we looked at the occlusion, and we described the
0.216 mm in Li to E-line is expected. For every cephalometric and profile changes.
millimeter of lower lip thickness (Li-L1) at T1, a The PAR index was developed to quantify the
reduction of 0.512 mm in Li to E-line is expected. extent to which a dentition deviates from an ideally
When we divided our pretreatment sample into 3 formed dental arch and occlusion. It does not assess
groups— horizontal (ANS-Me/N-Me ⱕ56%), normal other results, such as quality of life, reduced suscepti-
(56%⬍ ANS-Me/N-Me ⬍58%), and divergent (ANS- bility to oral diseases, and dysfunctions.13 The PAR
Me/N-Me ⱖ58%)—we found no significant differ- score gives a general impression of the dental arches
ences in the change of the measurements SN/ML (P ⫽ and the occlusion but does not take all dental variables
.429). The values for variable ANS-PNS/ML show that into account. For instance, in our study, the mandibular
the bite closed 0.1° in the divergent group and opened incisors were slightly proclined at T2. This does not
0.8° and 0.9° in the horizontal and normal groups, have a negative effect on the PAR score. This is a
American Journal of Orthodontics and Dentofacial Orthopedics Stalpers et al 321
Volume 132, Number 3

Table III.
Prediction of soft-tissues changes, results of
backward regression analysis
Beta P value 95% CI for beta

Dependent variable
Ls to E-line (T2⫺T1)
Independent variables
Included
Constant 1.192 .245 ⫺0.831 3.216
Overjet (T2⫺T1) 0.396 .000 0.214 0.578
Ls-U1 at T1 ⫺0.168 .021 ⫺0.309 ⫺0.206
Excluded
U1 to A-Pog (T2⫺T1)
U1L/ANS-PNS (T2⫺T1)
Sex at T1
Fig 2. Nomogram with PAR score at T1 compared with Model fit Adj R2: .153
Dependent variable
PAR score at T2 and improvement categories; 73% of
Li to E-line (T2⫺T1)
patients were in “greatly improved” section; no patients Independent variables
were in “worse or no different” section. Included
Constant 5.349 .000 2.601 8.097
L1 to A-Pog (T2⫺T1) 0.216 .019 0.036 0.396
Li-L1 at T1 ⫺0.512 .000 ⫺0.701 ⫺0.323
Excluded
L1L/ML (T2⫺T1)
Overjet (T2⫺T1)
Sex at T1
Model fit Adj R2: .234

error. We chose to use the interobserver error because


the intraobserver error cannot detect systematic errors
in the identification of cephalometric points. For 6 of
the cephalometric variables and the PAR score, a
systematic difference between the observers was found.
This was a matter of concern. However, for all 6
cephalometric variables, the systematic difference be-
tween the observers was small, always smaller than the
duplicate measurement error. The duplicate measure-
ment error in turn was much smaller than the standard
deviation of the variable concerned (a factor 4 for Li-L1
and more than a factor 10 for the other cephalometric
variables). In comparison with the variability of the
PAR scores in the patient group, the duplicate measure-
ment error for the PAR score was not as small (about
Fig 3. Mean tracings: black, T1; red, T2. Note relatively
half of the standard deviation for the PAR score). But
small changes in sagittal position of upper and lower
lips compared with greater changes in incisor position
when compared with the size of the treatment effect,
when superimposed on palatal plane at ANS. the duplicate measurement error was small (a differ-
ence of a factor 10). Therefore, the uncertainty added
by the measurement error was too small to consider
reason that we included cephalometric analysis in our exclusion of variables from the analysis.
study.14 In this study, the average PAR score at T1 was high.
For all cephalometric variables and the PAR score, Eighty-four of the 100 patients had an initial score of
a method error analysis was conducted, based on ⱖ22 points, and 15 was the lowest initial score.
duplicated measurements by a second orthodontist. In Thirteen patients had a PAR score of zero at T2; 10 was
most published studies, the intraobserver error is given. the highest PAR score at T2. Ten or fewer PAR points
This error is usually smaller than the interobserver are considered a slight deviation from normal occlu-
322 Stalpers et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2007

sion; 5 or fewer reflect nearly ideal occlusion.10,15 The variable upper lip position relative to the E-line
Previous studies showed that a 70% reduction of the (Ls to E-line) was suggested by Ricketts23 as a way to
PAR score can be considered a great improvement in evaluate the position of the upper lip relative to the chin
occlusal factors.11,16 In our study, the sample showed and nose. He found that ideally the upper lip should be
an 89.9% average reduction in PAR score. Other 4.0 mm posterior to this line in women and slightly
studies ranged from a 68% reduction in PAR score in more retruded in men. These values were similar to the
orthodontically treated British patients to 78% in a adult values of Bishara et al.21 They found, for 15-year-
sample treated by Norwegian orthodontists to 88% in a olds, that the upper lip was on average 2.9 mm posterior
study of American Board of Orthodontics cases.17-19 In of the E-line. We found, in our sample, the upper lip to
our study, no patients were in the “worse or no be on average 0.8 mm posterior of the E-line at T1 and
different” category at T2, whereas 73% of our patients 3.3 mm posterior of the E-line at T2. We retracted the
could be categorized as “greatly improved.” However, maxillary incisors on average 2.7 mm relative to the
all our patients had a Class II malocclusion with an A-Pog line and maintained good inclination. We ob-
enlarged overjet. Because overjet has a weighting of 6 served retrusion of the upper lip relative to the subna-
in the British weighting system, this adds considerably sale-soft-tissue-Pog line of 1.4 mm. This means that, in
to a high pretreatment PAR score. It is less difficult to our sample, the upper lip followed the movement of the
achieve striking, recordable changes when the initial maxillary incisors for about 50% after extraction of the
PAR score is high.20 Nevertheless, our study suggests first permanent maxillary molars. Also, Katsaros24
that the standard of the treatment was high. found only small soft-tissue profile changes compared
For the soft-tissue profile changes during orthodon- with the dental changes in identical twins, with 1 boy
tic treatment, normal growth changes should be kept in treated with extraction of 4 premolars and the other
mind. It was shown that the upper and lower lips without extractions. The relatively small changes in the
become significantly more retruded to the E-line with sagittal position of the lips with A-Pog as a reference
age.21,22 Ricketts23 found the lower lip in women to be line, compared with the larger changes measured with
2.0 mm posterior to the E-line; it was slightly more the E-line as the reference, show that the influence of
retruded in men. Bishara et al21 found the relative the growth of the chin or the nose on the facial profile
position of the lower lip to be, on average, 1.7 mm might be more important than the orthodontic treatment.
posterior to the E-line for adolescent boys and girls 15 In a stereophotogrammetric study on the growth of the
years of age. In the sample of Paquette et al,5 the lower nose, early growth was found in girls and late growth in
lips retruded 3.1 mm in the 4-premolar extraction group boys, suggesting an adolescent growth spurt in the nose.25
and 0.5 mm in the nonextraction group. In our study, Developmentally, the greatest change occurred in the
the lower lip at T1 was 0.1 mm anterior of the E-line. anteroposterior prominence of the nasal tip.
At T2, the lower lip was 1.6 mm posterior of the E-line, An important factor in our analysis was the predic-
a retrusion of 1.8 mm. An explanation for this obser- tion of changes in lip position for the individual patient.
vation might be that, since all our patients had an When we applied a backward regression model for the
enlarged overjet, the lower lip rested on the protruded upper lip, sex, change in maxillary incisor position, and
maxillary incisors at T1. Overjet was, in our patients, inclination did not seem to significantly influence the
corrected by retraction of the maxillary incisors, pro- change of the position of the upper lip in relation to the
clination of the mandibular incisors (since we did not E-line (Ls to E-line). However, change in overjet and
extract in the mandibular arch), and growth. When the initial upper lip thickness could explain 15% of the
maxillary incisors are retracted, the lower lip follows variation. For the prediction of the change of lower lip
this movement. We were able to retract the maxillary position, sex, overjet, and inclination of the mandibu-
incisors with a relatively controlled retroclination of larr incisors did not seem to have significant influence.
2.3°, but we could not avoid proclination of the However, mandibular incisor position (L1 to A-Pog)
mandibular incisors. The mandibular incisors pro- and initial lower lip thickness (Li-L1) could explain
clined on average 5.3° from 98.0° at T1 to 103.2° at 23% of the variation.
T2. This provided extra arch space and reduced the It was suggested that supraerupted maxillary first
amount of retraction needed for the maxillary inci- molars are a consistent finding in patients with skeletal
sors. This in turn provided for an improved profile in open bite.5 Therefore, extraction of these molars might
many patients.4 The standard deviations for the aid in mandibular autorotation and thereby reduce
changes in upper and lower lip thickness were high anterior facial height. In a sample of 8 patients with
(6.62 and 4.94, respectively). This indicates high anterior open bite treated orthodontically with the
individual variability. extraction of 4 first molars, closing of the bite of 1.5°
American Journal of Orthodontics and Dentofacial Orthopedics Stalpers et al 323
Volume 132, Number 3

(SN/GoGn angle) was found.26 These patients, how- 9. Riolo ML, Moyers RE, McNamara JA Jr, Hunter WS. An atlas
ever, had open bite extending to the posterior teeth. Our of craniofacial growth: cephalometric standards from the Uni-
versity School growth study. Craniofacial Growth Series. Ann
findings are not consistent with this treatment philoso- Arbor: Center for Human Growth and Development; University
phy. The only statistically significant difference be- of Michigan; 1974.
tween T1 and T2 with regard to the skeletal vertical 10. Richmond S, Shaw WC, O’Brien KD, Buchanan IB, Jones R,
measurements for the horizontal, normal, and divergent Stephens CD, et al. The development of the PAR index (peer
groups was found for the measurement ANS-PNS/ML. assessment rating: reliability and validity). Eur J Orthod 1992;
14:125-39.
The bite closed 0.1° in the divergent group and opened 11. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR
0.8° and 0.9° in the horizontal and normal groups, index (peer assessment rating): methods to determine the out-
respectively. This difference was statistically signifi- come of orthodontic treatment in terms of improvement and
cant, but the clinical relevance of this finding is limited. standards. Eur J Orthod 1992;14:180-7.
In other words, we did not find a bite-closing effect of 12. Dahlberg G. Statistical methods for medical and biological
students. New York: Interscience Publications; 1940.
our treatment. That means that divergent patients do not 13. Shaw WC, Richmond S, O’Brien KD. The use of occlusal
seem to benefit more from this treatment modality than indices: a European perspective. Am J Orthod Dentofacial
do deepbite patients. Orthop 1995;107:1-10.
14. Birkeland K, Furevik J, Boe OE, Wist PJ. Evaluation of
CONCLUSIONS treatment and posttreatment changes by the PAR index. Eur
J Orthod 1997;19:279-88.
Our results suggest that extraction of the maxillary 15. Richmond S, Shaw WC, Stephens CD, Webb WG, Roberts CT,
first permanent molars in Class II Division 1 patients Andrews M. Orthodontics in the general dental service of
leads to good treatment outcomes. Extraction of the England and Wales: a critical assessment of standards. Br Dent
maxillary first permanent molars has only a minor J 1993;174:315-29.
effect on the soft-tissue profile. The bite-closing effect 16. DeGuzman L, Bahiraei D, Vig KW, Vig PS, Weyant MS,
O’Brien KD. The validation of the peer assessment rating index
of extracting the maxillary first permanent molars is for malocclusion severity and treatment difficulty. Am J Orthod
statistically significant, but the clinical relevance is Dentofacial Orthop 1995;107:172-6.
questionable. 17. O’Brien KD, Shaw WC, Roberts CT. The use of occlusal indices
in assessing the provision of orthodontic treatment by the
hospital orthodontic service of England and Wales. Br J Orthod
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