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Exodoncia Premolares
Exodoncia Premolares
Introduction: Our aim was to assess the available evidence for the effects of orthodontic treatment with 4 pre-
molar extractions on the skeletal vertical dimension of the face compared with nonextraction treatment.
Methods: Electronic database searches (MEDLINE, EMBASE, Cochrane Oral Health Group's Trials Register,
and CENTRAL) of published and unpublished literature and hand searches of eligible studies were performed,
with no language or publication date restrictions. Two authors performed data extraction independently and in
duplicate. Risk of bias was assessed. Results: After application of the eligibility criteria, 14 studies were included
in this systematic review. All were retrospective. Risk of bias ranged from moderate to critical. Ten studies inves-
tigated patients with various skeletal vertical patterns and classes of malocclusion and found no difference
between extraction (Ex) and nonextraction (Nonex) treatment in regard to the vertical dimension. Only 2 studies
found statistically significant increases in the nonextraction groups, one in N-Me (Ex: 11.5 mm;
Nonex: 15.5 mm; P \0.05) and one in SN-GoGn (Ex: 0.9 ; Nonex: 10.8 ; P \0.05), but without a
concurrent significant change in other vertical measurements such as FMA. Two other studies showed
opposite findings regarding N-Me (Ex: 12.3 mm; Nonex: 10.9 mm; P \0.05) and FMA (Ex: 10.3 ; Nonex:
2.0 ; P\0.05). Conclusions: Although the quality of evidence ranged from moderate to low, there was consid-
erable agreement among these studies, suggesting that orthodontic treatment with 4 premolar extractions has
no specific effect on the skeletal vertical dimension. Thus, an extraction treatment protocol aiming to reduce or
control the vertical dimension does not seem to be an evidence-based clinical approach. (Am J Orthod
Dentofacial Orthop 2018;154:175-87)
E
xtractions for orthodontic purposes have always dimension during orthodontic treatment, this may be an
been a controversial issue in contemporary treatment additional major disputation. It has been advocated that
planning. When linked to the control of the vertical changes in vertical dimension during growth may also in-
a
fluence the anteroposterior position of the mandible and
Department of Orthodontics and Dentofacial Orthopedics, 251 Hellenic Air
Force Hospital, Athens, Greece.
the establishment of the permanent occlusion.1
b
Department of Orthodontics and Dentofacial Orthopedics, University of Bern, For many years, posterior tooth extractions have
Bern, Switzerland.
c
been suggested, especially in long-face patients to con-
Department of Orthodontics, Faculty of Dentistry, Aristotle University of Thessa-
loniki, Thessaloniki, Greece.
trol the vertical dimension.2 It has been recommended
d
Department of Orthodontics and Dentofacial Orthopedics, 251 Hellenic Air that extracting permanent teeth may correct an open
Force Hospital, Athens, Greece; Department of Orthodontics and Dentofacial Or- bite or reduce the vertical dimension of the face by coun-
thopedics, University of Bern, Bern, Switzerland.
The first 2 authors contributed equally to this work.
terclockwise rotation of the mandible, through the for-
All authors have completed and submitted the ICMJE Form for Disclosure of Po- ward movement of the posterior teeth: the wedge-type
tential Conflicts of Interest, and none were reported. effect.3-5 According to various authors, extractions
Address correspondence to: Nikolaos Gkantidis, Department of Orthodontics and
Dentofacial Orthopedics, University of Bern, CH-3010, Freiburgstrasse 7, Bern,
lead to reduction of the vertical dimension not only in
Switzerland; e-mails, nikosgant@yahoo.gr; nikolaos.gkantidis@zmk.unibe.ch. hyperdivergent patients, but also in those with skeletal
Submitted, January 2018; revised and accepted, March 2018. open bite.6,7 On the other hand, other studies reported
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
no distinct effects of extraction treatment on the facial
https://doi.org/10.1016/j.ajodo.2018.03.007 vertical dimension.8,9
175
176 Kouvelis et al
Hyperdivergent patients comprise a significant part Unpublished literature was searched on ClinicalTrials.
(22%) of the orthodontic patients treated worldwide.10 gov, the National Research Register, and Pro-Quest
Thus, the selection of an extraction vs a nonextraction Dissertation Abstracts and Thesis database. We attemp-
treatment protocol in regard to effects in the vertical ted to identify all relevant studies irrespective of lan-
dimension is a common decision made in every practice. guage. The reference lists of all eligible studies were
The contradictory findings of previous studies, however, hand searched for additional studies.
do not allow for evidence-based decision making, lead-
Selection of studies
ing, in turn, to extremely different strategies applied to
patients by various clinicians. Studies were selected independently and in duplicate
Therefore, the aim of this review was to systemati- by 2 authors (G.K., K.D.) who were not blinded to the
cally search the literature to evaluate the effects of 4 identity of the authors of the studies, their institutions,
premolar extractions compared with nonextraction or the results of their research. Study selection proced-
treatment on the skeletal vertical dimension of the ures comprised reading of titles, abstracts, and full texts.
face. After they excluded noneligible studies, the full report of
publications considered eligible for inclusion by either
MATERIAL AND METHODS author was obtained and assessed independently. Dis-
Protocol and registration
agreements were resolved by discussion and consulta-
tions with other authors (I.D., N.G.). A record of all
The protocol was not registered prior to the study. decisions on study identification was kept.
Selection criteria applied for the review Data extraction and management
Any study design was considered eligible for inclu- Data extraction was performed independently and in
sion in this review, including randomized clinical trials, duplicate by the first 2 authors (G.K., K.D.). To record the
nonrandomized or quasi-randomized controlled trials, desired information, customized data collection forms
and prospective and retrospective studies with a treated were used. Disagreements were resolved in reevaluations
comparison or control group. of the original studies by both authors and discussions
Patients of any age having orthodontic treatment with the last author until consensus was reached.
with full fixed appliances in the maxilla and mandible
were eligible. Measures of treatment effect
Orthodontic therapy with fixed appliances including For continuous outcomes, mean differences and
4 premolar extractions (1 in each quadrant) were eligible. standard deviations were used to summarize the data
For the control or comparison group, we chose or- from each study.
thodontic therapy with fixed appliances, but without
tooth extractions. Unit of analysis
The outcome was the effects on the vertical dimen-
In all cases, the unit of analysis was the patient.
sion of skeletal craniofacial structures, quantitatively as-
sessed on radiographic images.
Missing data
The follow-ups included before and after orthodon-
tic treatment evaluations. We contacted the authors via e-mail to request infor-
Exclusion criteria were animal and in-vitro studies, mation that was missing. In case of no response, only the
studies involving orthognathic surgery, and case reports available data were reported and analyzed. For missing
or studies reporting outcomes from fewer than 10 pa- standard deviations, data could be retrieved if t statistics
tients. or P values were reported. When P values were reported
as P50.000, we considered them rounded values and
Search strategy for identification of studies made a worst case scenario hypothesis, imputing the
value to be 0.0004 instead.
Detailed search strategies were developed and appro-
priately revised for each data base, considering the dif-
Assessment of heterogeneity
ferences in controlled vocabulary and syntax rules. The
following electronic databases were searched: MEDLINE Heterogeneity can be divided into 3 forms: clinical,
(via Ovid and PubMed, from 1946 to August 2, 2017; methodological, and statistical.11 We assessed clinical
Appendix), EMBASE (via Ovid), Cochrane Oral Health heterogeneity by examining the characteristics of the
Group's Trials Register, and CENTRAL. studies, the similarities between the participants, the
August 2018 Vol 154 Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Kouvelis et al 177
interventions, and the outcomes as specified in the in- especially in terms of risk of bias. Finally, the tool we
clusion criteria. We determined whether the participants used to assess risk of bias provided a summary measure
had completed their growth as participant-specific com- that also accounted for heterogeneity assessment.12
ponents. We also identified the vertical skeletal pattern
and the sagittal skeletal and dental patterns as potential Assessment of reporting bias
population-specific sources of clinical heterogeneity. Reporting biases arise when the reporting of research
The potential effect of varying sex distribution between findings is affected by the nature or direction of the find-
studies was ignored, since a differential effect due to sex ings themselves. We attempted to minimize potential re-
was not expected and angular measurements were porting biases, including publication bias, multiple
mainly considered. On the other hand, treatment proto- (duplicate reports) publication bias, and language bias
col was considered to add to the total clinical heteroge- in this review by conducting an accurate and sensitive
neity, and the following aspects were underlined: type of search of many sources with no language restriction.
anchorage, treatment biomechanics (eg, headgear appli- We also searched for ongoing trials.
cation), type of teeth extracted, and type of control
group. The final component of clinical heterogeneity
was outcome measures, since the vertical changes can Quality assessment
be measured on a lateral cephalogram in various ways. The quality assessments of the included studies were
Methodologic heterogeneity was considered in terms conducted using the ROBINS-I tool.12 Two authors
of both study design and conduct, in the latter case, (G.K., K.D.) assessed the studies individually and then
American Journal of Orthodontics and Dentofacial Orthopedics August 2018 Vol 154 Issue 2
178 Kouvelis et al
August 2018 Vol 154 Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
American Journal of Orthodontics and Dentofacial Orthopedics
Kouvelis et al
Table I. Main characteristics of the included studies
Extraction group (Ex) Nonextraction group (Nonex)
179
August 2018 Vol 154 Issue 2
180
Table I. Continued
Kouvelis et al
(1992) dimension of extractions treatment Normodivergent Nonex: 1.6 y (2) N-Me (mm)
Retrospective Class II patients n 5 33 (20 F, n 5 30 (11 F, Ex: 22.9 (3) ANS-Me
13 M) 19 M) Nonex: 24.9 (mm)
age, 12.5 y age, 12.6 y
Kouvelis et al 181
magnification
Class II normodivergent extraction patients with Class
II hypodivergent nonextraction patients and also found
no difference.16
(1) MP-HP ( ) NA
not define the vertical growth pattern of their sam-
(3) ANS-Me
interest
(3) N-ANS/
ANS-Me
extractions in Class I patients with bimaxillary
(ratio)
(mm)
protrusion, compared with nonextraction treatment in
( )
( )
Nonex: 2.9 y
treatment
NA
DISCUSSION
Malocclusion/Skeletal
Dental Class I
Dental Class I
elastics, and
Treatment
NA
Nonextraction
Nonextraction
Nonextraction
n 5 29 (18 F,
treatment
treatment
treatment
Age, 12.8 y
11 M)
n 5 45
all patients
details
Changes in vertical Four first premolar Lip bumper,
extractions
extractions
extractions
beliefs.
Class I patients n 5 38
dimension of
dimension of
Retrospective
Retrospective
Study design
Porto et al17
(2012)
(2008)
(1994)
Year
American Journal of Orthodontics and Dentofacial Orthopedics August 2018 Vol 154 Issue 2
August 2018 Vol 154 Issue 2
182
Table II. Risk of bias of the included studies
Bias in measurement Bias due to deviations
Selection classification of from intended Bias due to Bias in measurement Bias in selection of
Study Confounding bias interventions interventions missing data of outcomes reported result Overall
Basciftci and Class I: Moderate Moderate No information Low Moderate Moderate Serious
Usumez23 moderate (extracted premolars (NA treatment details) (not blinded assessor)
(2003) not defined)
Class II: critical Moderate Moderate No information (NA Low Moderate Moderate Critical
(difference in age and (extracted premolars treatment details) (not blinded assessor)
SN-GoGn pretreatment) not defined)
Bravo et al22 Moderate Moderate Moderate No information (NA Low Moderate Moderate Serious
(1997) (2 extraction patterns treatment details) (not blinded assessor)
were used)
Gkantidis et al8 Moderate Low Low Low Low Moderate Low Moderate
(2011) (not blinded assessor)
Hayasaki et al9 Moderate Moderate Low Low Low Moderate Low Moderate
(2005) (not blinded assessor)
Hosseinzadeh-Nik Moderate Moderate Low No information Low Moderate Moderate Serious
et al21 (NA treatment details) (not blinded assessor)
(2016)
American Journal of Orthodontics and Dentofacial Orthopedics
Katsaros et al24 Moderate Moderate Moderate No information (NA Low Moderate Low Serious
(1996) (extracted premolars treatment details) (not blinded assessor)
not defined)
Kirschneck et al13 Moderate Low Low Moderate (treatment details Low Low Low Moderate
(2015) partially provided)
Kocadereli14 Moderate Moderate Low Moderate Low Moderate Low Moderate
(1999) (treatment details partially (not blinded assessor)
provided)
Kumari and Fida15 Serious Moderate Low Moderate Low Serious Serious Serious
(2010) (unknown treatment time (treatment details partially (no method error, not (only posttreatment
and sex distribution) provided) blinded assessor) values compared)
Luppanapornlap and Critical Low Low No information (NA Low Moderate Low Critical
Johnston16 (different group baseline treatment details) (not blinded assessor)
(1993) characteristics)
Paquette et al20 Moderate Low Low No information (NA Low Moderate Low Serious
(1992) treatment details) (not blinded assessor)
Porto et al17 Moderate Moderate Low Low Low Moderate Low Moderate
(2012) (not blinded assessor)
Sivakumar and Critical Moderate Low No information (NA Low Moderate Low Critical
Valiathan18 (differences in treatment treatment details) (not blinded assessor)
Kouvelis et al
(2008) time and sex distribution)
Staggers19 No Information Moderate Low No information (NA Low Serious Low Critical
(1994) (baseline table missing, treatment details) (NA method error, not
unknown sex distribution) blinded assessor)
American Journal of Orthodontics and Dentofacial Orthopedics August 2018 Vol 154 Issue 2
184 Kouvelis et al
Author
Year Results
Study design Intervention Mean 6 SD of T1-T0 difference Effect on vertical dimension
Kumari and Fida 15
4 first premolar Ex FMA ( ), Ex: 0.2; Nonex: 10.6; P .0.050 There is a statistically significant increase in
(2010) vs Nonex N-Me (mm), Ex: 11.5; Nonex: 15.5; N-Me distance (4 mm) in the nonextraction
Retrospective P \0.05* compared with extraction treatment in skeletal
N-ANS/ANS-Me, Ex: 0.0, Nonex: 11.1; Class I hyperdivergent patients; no difference
P .0.050 was detected in FMA angle and N-ANS/ANS-
Me ratio.
Luppanapornlap and 4 first premolar Ex vs Nonex FMA ( ), Ex: 0.2, Nonex: 10.7; P .0.050 There is no difference between extraction and
Johnston16 N-Me (mm), Ex: 15.4; Nonex: 15.0; nonextraction treatment in dental Class II, 1
(1993) P .0.050 patients.
Retrospective ANS-Me (mm), Ex: 12.7, Nonex: 13.4;
P .0.050
Paquette et al20 4 first premolar Ex vs Nonex FMA ( ), Ex: 10.3; Nonex: 2.0; There is a statistically significant, but clinically
(1992) P \0.010* questionable decrease in FMA angle (2.3 ) in
Retrospective N-Me (mm), Ex: 15.4; Nonex: 17.0; the nonextraction compared to extraction
P .0.050 treatment in dental Class II, 1 normodivergent
ANS-Me (mm), Ex: 13.0, Nonex: 13.9; patients; no difference was detected in
P .0.050 N-Me or ANS-Me distance.
Porto et al17 4 first premolar Ex vs Nonex SN-GoGn ( ), Ex: 0.9 6 2.4; There is a statistically significant, but clinically
(2012) Nonex: 10.8 6 2.3; P 5 0.020* questionable increase in SN-GoGn angle (1.7 )
Retrospective FMA ( ), Ex: 0.3 6 3.1; in nonextraction compared with extraction
Nonex: 10.7 6 2.5; P 5 0.240 treatment in dental Class II, 1 hyperdivergent
patients; no difference was detected in FMA
angle.
Sivakumar and 4 first premolar Ex vs Nonex FMA ( ), Ex: 10.5 6 1.7; There is a statistically significant, but clinically
Valiathan18 Nonex: 10.1 6 2.0; P 5 0.985 questionable increase in N-Me distance
(2008) N-Me (mm), Ex: 12.3 6 3.0; (1.4 mm) in the extraction compared with
Retrospective Nonex: 10.9 6 2.1; P 5 0.033* nonextraction treatment in dental Class I
ANS-Me (mm), Ex: 11.3 6 1.3; normodivergent patients; no difference was
Nonex: 10.6 6 1.8; P 5 0.080 detected in FMA angle and ANS-Me distance.
Staggers19 4 first premolar Ex vs Nonex MP-HP ( ), Ex: 10.1 6 2.5; There is no difference between extraction and
(1994) Nonex: 10.1 6 2.0; P 5 0.950 nonextraction groups in dental Class I
Retrospective N-Me (mm), Ex: 15.4 6 4.7; patients.
Nonex: 15.1 6 3.6; P 5 0.740
N-ANS/ANS-Me, Ex: 1.4 6 3.8; Nonex:
2.7 6 3.2; P 5 0.090
NA, Not available; Ex, extraction; Nonex, nonextraction; Class II, 1, Class II Subdivision 1.
*P \0.05.
greater than 1.2 in either extraction or nonextraction The craniofacial complex, including the masticatory sys-
group. Thus, these changes cannot be considered to tem, is complicated and should not be perceived as a
have clinical significance. simple articulator. There are probably more important
The main rationale behind the supposition that tooth factors than tooth numbers responsible for the establish-
extractions reduce the vertical dimension is based on the ment of the vertical positions of the teeth and the asso-
wedge-effect concept, according to which the mesial ciated skeletal patterns, such as neuromuscular balance
movement of the molars during closure of the extraction and function.8
spaces reduces the vertical dimension by anterior rota- For the patterns of extractions, various combinations
tion of the mandible.25 However, this concept has not have been reported in the literature and are used in clinical
been proven. A possible explanation for this, as reported practice; the most popular is 4 first or second premolar
by Gkantidis et al,8 is that the direction of the mesializa- extraction treatment. For this reason, our review focused
tion of the posterior teeth during space closure is parallel only on these patterns. A preliminary literature search iden-
to the occlusal plane, and not to the maxillary and tified studies that tested the extraction of 4 first or
mandibular planes for the maxillary and mandibular second molars7,19,26 or 2 mandibular premolars,27 but these
teeth, respectively, as the wedge-effect theory suggests. did not have a treated nonextraction control group.
August 2018 Vol 154 Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Kouvelis et al 185
Most studies in this review assessed hyperdivergent all included studies were retrospective, and this is an
rather than normodivergent patients, and no study had inherent limitation of this review, since retrospective
an extraction group consisting of only hypodivergent studies are prone to various types of biases and especially
patients, supporting the widely accepted clinical belief to selection bias. The lack of prospective or randomized
that a hypodivergent profile is a contraindication for ex- clinical trials might be attributed to the difficulty in col-
tractions, whereas hyperdivergency is an indication for lecting these samples prospectively, for both practical
extractions. In contrast to this, we found no difference and ethical concerns.
in normodivergent and hyperdivergent patients. Only
Kumari and Fida15 found a clinically significant increase CONCLUSIONS
in N-Me distance (4 mm) in nonextraction compared In this systematic review, it was reasonable to
with extraction treatment, but the study had a serious conclude that there is no specific effect of 4 premolar
risk of bias and inadequate reporting of the results. extraction treatment compared with nonextraction
Furthermore, it did not detect a difference in FMA. treatment protocols on the vertical dimension of the
Considering the growth status, most studies included face. Despite the low to moderate quality of evidence,
both growing and nongrowing patients. Some studies there is considerable agreement among the available
attempted to control the confounding due to growth studies that an extraction protocol to reduce or control
status, age, and sex by including only female pa- vertical dimension is not justified. Although randomized
tients13,22,24 or having a similar sex distribution controlled trials may not be feasible for such treatment
between the compared groups.8,9,17,23 Three studies options, well-conducted prospective cohort studies
included only nongrowing patients.15,18,21 would be desirable to confirm this statement.
Regarding malocclusions, most studies included pa-
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APPENDIX
American Journal of Orthodontics and Dentofacial Orthopedics August 2018 Vol 154 Issue 2