ORIGINAL ARTICLE

Cephalometric evaluation of symmetric and

asymmetric extraction treatment for patients
with Class II subdivision malocclusions
Guilherme Janson,a Paulo Eduardo Guedes Carvalho,b Rodrigo Hermont Cançado,b
Marcos Roberto de Freitas,a and José Fernando Castanha Henriquesa
Bauru, Brazil

Introduction: The purpose of this study was to cephalometrically compare the dentoskeletal and soft-tissue
changes consequent to orthodontic treatment in patients with Class II subdivision malocclusion treated with
asymmetric and symmetric extractions. Methods: The sample included 54 patients with Class II subdivision
malocclusion and full complement of permanent teeth, including first molars, at the beginning of treatment.
Patients in group 1 (n ⫽ 27) were treated with the asymmetric extraction of 3 premolars and had initial and
final mean ages of 14.07 and 16.71 years. Patients in group 2 (n ⫽ 27) were treated with the symmetric
extraction of 4 premolars and had initial and final mean ages of 13.35 and 15.75 years. Lateral cephalometric
radiographs were taken at pretreatment and posttreatment. T tests were used to compare the groups at
pretreatment and the treatment changes between groups. Results: The results demonstrated that the
asymmetric extraction group had significantly less mandibular incisor retraction, less soft-tissue retraction,
and greater increases in mandibular incisor extrusion and mandibular molar asymmetry index than the
symmetric extraction group. Conclusions: It was concluded that the 3-premolar asymmetric extraction
protocol in Class II subdivision malocclusions produces significantly less mandibular incisor and soft-tissue
retraction than the 4-premolar extraction protocol. (Am J Orthod Dentofacial Orthop 2007;132:28-35)

reatment of Class II subdivision malocclusions tissues in Class II subdivision malocclusions treated with

T with 3 premolar extractions provides a better

occlusal result compared with 4-premolar ex-
traction treatment.1 Because only 1 premolar is ex-
3 premolar extractions, are similar to the 4-premolar
extractions protocol.”

tracted in the mandibular arch in the 3-premolar extrac-

tion protocol, it seems reasonable to assume that the
cephalometric changes, especially the amounts of man-
dibular incisor and soft-tissue retractions are smaller than
in the 4-premolar extraction protocol. However, whether
these amounts of retraction are significantly different
between the 2 extraction protocols has not been evaluated
to definitely support this assumption. Therefore, the ob-
jective of this investigation was to test the following null
hypothesis: “the cephalometric changes, especially the
amounts of retraction of the mandibular incisors and soft
Department of Orthodontics, Bauru Dental School, University of São Paulo,
Brazil.
a
Professor.
b
Graduate student.
Based on research by Paulo Eduardo Guedes Carvalho in partial fulfillment of
the requirements for the degree of PhD in orthodontics at Bauru Dental School,
University of São Paulo.
Reprint requests to: Guilherme Janson, Department of Orthodontics, Bauru
Dental School, University of São Paulo, Alameda Octávio Pinheiro Brisolla
9-75, Bauru, SP, 17012-901, Brazil; e-mail, jansong@travelnet.com.br.
Submitted, March 2005; revised and accepted, July 2005.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.07.024
28
MATERIAL AND METHODS
The sample, retrospectively selected from the files
of the orthodontic department at Bauru Dental School,
University of São Paulo, Brazil, consisted of initial and
final lateral cephalometric radiographs of 54 Class II
subdivision malocclusion patients, treated with edge-
wise appliances, divided into 2 groups. Group 1 in-
cluded 27 patients (12 male, 15 female) treated with 3
asymmetric extractions, at an initial mean age of 14.07
years (SD ⫽ 1.60; range, 11.08-17.00 years). Group 2
included 27 patients (12 male, 15 female) treated with
4 symmetric extractions, at an initial mean age of 13.35
years (SD ⫽ 1.33; range, 11.33-15.75 years). The
selection criteria were full Class II molar relationship
on 1 side and Class I molar relationship on the other, as
well as all permanent teeth present up to the first
molars. Sample selection was based exclusively on the
initial anteroposterior dental relationship, regardless of
any other dentoalveolar or skeletal characteristic. For-
ty-seven patients had Class II Division 1 subdivision
malocclusions (22 in group 1, 25 in group 2), and 7 had
Class II Division 2 subdivision malocclusions (5 in
American Journal of Orthodontics and Dentofacial Orthopedics Janson et al 29
Volume 132, Number 1

Table I. Definitions of less usual cephalometric variables

Mx6-PTV (mm) Perpendicular distance from most posterior point on distal surface of maxillary first permanent molar to pterygoid vertical
plane (PTV)
Mx6-PP (mm) Perpendicular distance from mesiobuccal cusp of maxillary first molar to palatal plane
Md6-PTV (mm) Perpendicular distance from most posterior point on distal surface of mandibular first permanent molar to PTV
Md6-MP (mm) Perpendicular distance from mesiobuccal cusp of mandibular first molar to mandibular plane
Mx1.NA (°) Maxillary incisor long axis to NA angle
Mx1-NA (mm) Distance between most anterior point of maxillary incisor crown and NA line
Mx1.PP (°) Maxillary incisor long axis to palatal plane angle
Mx1-Aperp (mm) Perpendicular distance from most anterior point of maxillary incisor crown to Frankfort perpendicular line, through
A-point
Mx1-PP (mm) Perpendicular distance between maxillary central incisor edge and palatal plane
Md1.NB (°) Mandibular incisor long axis to NB angle
Md1-NB (mm) Distance between most anterior point of mandibular incisor crown and NB line
Md1.MP (°) Mandibular incisor long axis to mandibular plane angle
Md1-Bperp (mm) Perpendicular distance from most anterior point of mandibular incisor crown to mandibular plane perpendicular, through
B-point
Md1-MP (mm) Perpendicular distance between incisal edge of mandibular incisor and mandibular plane
H.NB (°) Line H (harmony line, tangent to soft-tissue chin and upper lip32) to NB angle
H-Pr (mm) Perpendicular distance between line H and Pr (most anterior point of nose)
H-LL (mm) Perpendicular distance between line H and LL (most anterior point of lower lip)

group 1, 2 in group 2). The extractions included
especially the first premolars, with only 4 patients of
group 1 and 3 of group 2 having extractions of the
second premolars. Two patients of group 1 had extrac-
tion of 1 mandibular second premolar, 1 had extraction
of 1 maxillary second premolar, and 1 had extraction of
1 maxillary and 1 mandibular second premolars. Three
patients of group 2 had extractions of the mandibular
second premolars.
The mechanics used with fixed edgewise appli-
ances are 0.022 ⫻ 0.028-in brackets, with extraoral
headgear and lip bumper to reinforce anchorage for
the maxillary and mandibular teeth, respectively,
when necessary. Class II elastics are also used when
needed, especially in the 4-premolar extraction pro-
tocol, to aid in correcting the molar Class II antero-
posterior relationship. Additionally, anterior diago-
nal elastics are used to correct the maxillary to
mandibular midline deviation in the 4-premolar ex-
traction protocol. There is no anchorage preparation.
The usual wire sequence begins with a 0.015-in
twist-flex or 0.016-in nickel-titanium alloy wire,
followed by 0.016, 0.018, 0.020, and 0.021 ⫻ 0.025
or 0.018 ⫻ 0.025-in stainless steel wire (3M Unitek,
Monrovia, Calif). In the extraction quadrants, the
canines are initially retracted a small amount only to
allow space for leveling and aligning of the anterior
teeth. The anterior teeth are retracted en masse with
the rectangular wire, after leveling and aligning. In
the 3-premolar extraction protocol, anterior retrac-
tion is performed only in the extraction quadrants.
With this procedure, the deviated mandibular dental
midline to the facial midplane is automatically cor-
rected in the 3 premolar extraction protocol. If a
0.021 ⫻ 0.025-in wire is used, the dimensions of the
rectangular wire are electrolytically reduced in the
posterior segments to lower the friction forces with
the brackets and tubes. Retraction of the canines and
the anterior teeth is performed with elastic chains.
Deep overbites are usually corrected by reversing
and accentuating the curve of Spee of the stainless
steel archwires from the beginning, until an overcor-
rection is obtained. This overcorrection is maintained
by accentuating and reversing the curve of Spee in
the rectangular wire as well. Fixed or removable
functional appliances were not used in the groups.
Lateral cephalometric radiographs of the patients of
both groups were obtained from each subject at 2
stages: before treatment (T1) and immediately after
treatment (T2). The lateral headfilms were obtained
with different x-ray machines, which produced differ-
ent magnification factors of the images that were
between 6% and 10.94%.
Two tracings were drawn from each headfilm: 1
to evaluate the conventional cephalometric treatment
changes and the other to evaluate the asymmetry
changes in each group (Table I, Figs 1-3). Dentoal-
veolar and skeletal asymmetries were evaluated ac-
cording to the method of Alavi et al,2 as follows.
Cephalometric films were traced and landmarks des-
ignated before digitization. Although the right and
left sides can be difficult to distinguish in asymmet-
ric patients, this did not affect the outcome of the
study because only absolute values of the difference
between the sides rather than signed differences were
used in the group comparisons. In addition, reference
30 Janson et al
Fig 1. Skeletal and soft-tissue cephalometric variables:
A, SNA angle; B, SNB angle; C, ANB angle; D, Co-A; E,
Co-Gn; G, SNGoGn; H, FMA; I, LAFH (lower anterior
face height); J, HNB; K, H-Pr; L, H-LL.
was made to the original models to identify the left
and right sides. The following landmarks were dig-
itized: sella, nasion, basion, bilateral orbitale, ptery-
gomaxillary fissure, antegonia, gonia, articulare,
points of maximum concavity on the anterior surface
of the ramus, and the most posterior points on the
distal surfaces of the maxillary and mandibular first
permanent molars. A reference line was determined
by constructing a perpendicular to the sella-nasion
line through basion. Linear measurements were made
in a horizontal direction from the bilateral orbitale
and pterygomaxillary fissure, articulare, anterior ra-
mal point, antegonion, and gonion, to the constructed
vertical line (Fig 3). Skeletal asymmetry was evalu-
ated by determining the absolute difference between
measurements for the right and left landmarks. Indi-
vidual measurements of asymmetry were then com-
bined to produce indexes of anteroposterior maxil-
lary and mandibular asymmetries, producing 2
skeletal variables.2
Linear measurements were also made from the
bilateral maxillary and mandibular molar points to the
vertical reference line. The absolute difference between
right and left landmarks was determined to arrive at
measurements of anteroposterior maxillary and man-
dibular molar asymmetries, resulting in 2 dentoskeletal
variables2 (Fig 3).
American Journal of Orthodontics and Dentofacial Orthopedics
July 2007
Fig 2. Dental cephalometric variables: M, Mx1.NA; N,
Mx1-NA; O, Mx1.PP; P, Mx1-Aperp; Q, Mx1-PP; R,
Md1.NB; S, Md1-NB; T, Md1.MP; U, Md1-Bperp; V, Md1-
MP; W, Mx6-PTV; X, Mx6-PP; Y, Md6-PTV; Z, Md6-MP.
The cephalometric tracings and landmark identi-
fication were made on acetate paper by 1 investigator
(P.E.G.C.) and then digitized with a digitizer (Accu-
Grid XNT, model A30TL.F, Numonics, Montgomer-
yville, Pa). These data were analyzed with software
(version 7.02, Dentofacial Planner, Toronto, Ontario,
Canada), which corrected the image magnification
factors of the radiographs.
To evaluate the initial malocclusion severity com-
patibility of the groups, the treatment priority index
(TPI)3 and the amount of mandibular crowding of each
subject were blindly calculated on the pretreatment
dental study models. The TPI provides weighted sub-
scores for the description of overjet, vertical overbite or
open-bite, tooth displacement, and posterior crossbite,
as well as summary scores for the overall severity of the
malocclusion. With the exception of rotation and dis-
placement, all TPI components are measured on a
continuous scale from positive to negative values.
Thus, mandibular overjet and open bite are entered as
negative overjet and negative overbite, respectively. A
constant corresponding to the first molar relationship is
added to the TPI score. Total scores on the TPI range
from 0 to 10 or more, with higher scores representing
more severe malocclusions.4,5
TPI components are defined as follows.4,5
Overjet is the anterior distance from the most
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 1
Fig 3. Dentoalveolar and skeletal asymmetry variables:
A, maxillary asymmetry; B, mandibular asymmetry; C,
maxillary first permanent molar asymmetry; D, mandib-
ular first permanent molar asymmetry.
mesial part of the labial surface of the maxillary
central incisor to the labial surface of the opposing
mandibular incisor, measured perpendicularly to the
coronal plane.
With the dental models in centric (convenience)
occlusion, overbite or open-bite is the amount of vertical
overlap of the maxillary central incisor over the
mandibular central incisor as a ratio of the total
crown height (cervix to incisal edge) of the mandib-
ular incisor.
Tooth displacement is the sum of the number of
teeth noticeably rotated or displaced from ideal align-
ment, plus 2 times the number of teeth rotated more
than 45° or displaced more than 2 mm.
First molar relationship is a constant comprising the
severity of the malocclusion, based on the relationship
between the maxillary and mandibular first molars.
Posterior crossbite measures buccolingual deviation
in the occlusion of the postcanine teeth. The measure-
ment is positive for buccal crossbite (first molar posi-
tioned too far to buccal), and negative for lingual
crossbite. Crossbite is also scored as the number of
teeth deviating from ideal cusp-to-fossa fit by a cusp-
to-cusp relationship or worse.4,5
Mandibular crowding of the initial dental study
models was calculated as the difference between arch
length (circumference, from left to right first molars)
and the sum of tooth widths from first molar to first
molar, in millimeters. In a well-aligned arch, arch
length was equal to the sum of the tooth widths.6
Janson et al 31
Ten randomly selected radiographs were retraced,
redigitized, and remeasured by the same examiner. The
casual error was calculated according to Dahlberg’s
formula,7 S2 ⫽ ⌺d2/2n, where S2 is the error variance
and d is the difference between 2 determinations of the
same variable, and the systematic error with dependent
t tests, at P ⬍.05.8-11
Statistical analysis
To apply the t test, a normal distribution of the
samples is necessary. This was verified with the Kol-
mogorov-Smirnov test. Results of this test demon-
strated that all variables had normal distribution. There-
fore, the independent t test was used for comparison
between groups at T1 to evaluate their compatibility.
Comparison of the numbers of patients with second
premolar extractions in the groups was conducted with
the chi-square test. Comparisons of the changes in the
variables during the treatment period (T2-T1) between
groups were also conducted with independent t tests.
Results were regarded as significant at P ⬍.05. These
analyses were performed with software (Statistica for
Windows, version 4.3B, Statsoft, Tulsa, Okla).
RESULTS
None of the variables had statistically significant
systematic errors, and casual errors varied from 0.06
(Co-A) to 0.21 (MxAsym).
Groups 1 and 2 were similar regarding numbers of
patients with second premolar extractions, initial ages,
crowding amounts, malocclusion severities, and all
cephalometric variables (Table II).
The results demonstrated that the asymmetric ex-
traction group had significantly less mandibular incisor
linear retraction, less soft-tissue retraction, and greater
increases in mandibular incisor extrusion and mandib-
ular molar asymmetry index than the symmetric extrac-
tion group (Table III). The other treatment changes
were similar in both groups.
DISCUSSION
The groups were similar regarding the numbers of
patients with second premolar extractions, initial ages,
crowding amounts, malocclusion severities, and ceph-
alometric variables (Table II). This compatibility had to
be ensured to detect minor differences between the
groups. To obtain this, it was necessary to eliminate
some subjects from both groups to match the ages.
Changes in the maxillary and mandibular compo-
nents showed no significant differences between the
groups with the different treatment protocols (Table
III). This result seems reasonable because the extrac-
tion protocols for the maxillary arch were similar, and
32 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2007

Table II. Comparison between groups 1 and 2 at T1 (chi-square and t tests)

Group 1 (n ⫽27) Group 2 (n ⫽ 27)

Variables Mean SD Mean SD P

Patients with second premolar extraction 4 3 .224*

Initial age (y) 14.07 1.60 13.35 1.33 .078
Crowding (mm) 2.81 1.38 2.94 1.62 .729
Initial TPI 8.18 3.31 8.64 2.92 .590
Maxillary component
SNA (°) 82.19 3.59 82.55 3.30 .701
Co-A (mm) 84.03 4.14 83.56 4.85 .705
Mandibular component
SNB (°) 77.45 3.85 77.57 2.72 .893
Co-Gn (mm) 109.52 5.43 106.98 5.58 .096
Maxillomandibular relationship
ANB (degrees) 4.74 2.69 4.97 2.15 .735
Diff Mx-Md (mm) 25.49 4.65 23.42 3.87 .080
Growth pattern
SN.GoGn (degrees) 33.10 4.40 33.91 5.20 .542
FMA (degrees) 26.35 5.03 26.95 5.00 .658
LAFH (mm) 65.68 5.48 64.35 5.29 .366
Posterior dentoalveolar component
Mx6-PTV (mm) 15.88 3.74 16.03 2.73 .862
Mx6-PP (mm) 23.78 2.74 22.72 2.63 .155
Md6-PTV (mm) 14.61 4.05 14.88 2.77 .773
Md6-MP (mm) 29.94 2.75 29.04 1.95 .171
Anterior maxillary dentoalveolar component
Mx1.NA (degrees) 25.06 9.16 25.52 6.05 .826
Mx1-NA (mm) 5.13 3.12 5.03 3.09 .903
Mx1.PP (degrees) 115.34 9.70 115.64 5.60 .892
Mx1-Aperp (mm) 5.28 3.18 5.51 3.19 .795
Mx1-PP (mm) 27.82 2.51 27.38 2.53 .530
Anterior mandibular dentoalveolar component
Md1.NB (degrees) 30.27 5.99 30.39 6.05 .942
Md1-NB (mm) 6.08 2.10 6.24 2.43 .793
Md1.MP (degrees) 97.54 6.62 96.39 6.77 .530
Md1-Bperp (mm) 7.55 2.43 7.45 2.66 .886
Md1-MP (mm) 39.42 2.94 39.26 3.18 .849
Soft-tissue component
H.NB (degrees) 14.39 4.63 15.30 3.95 .444
H-Pr (mm) 1.80 3.81 0.73 3.86 .310
H-LL (mm) 1.61 1.78 2.26 1.71 0.176
Skeletal and dentoskeletal asymmetries
MxAsym (mm) 2.11 1.35 2.01 1.70 .815
MdAsym (mm) 1.58 1.18 1.47 1.02 .731
Mx6Asym (mm) 1.96 1.43 1.83 0.83 .685
Md6Asym (mm) 2.14 1.12 2.02 1.20 .728

Diff, Difference.
*Chi-square test.

no significant differences were found in maxillary
incisor changes, as will be later discussed. In the
mandibular component, although greater incisor retrac-
tion was observed in the 4-premolar extraction proto-
col, it did not reflect significant retraction of B-point to
produce intergroup differences in SNB angle. Obvi-
ously, these 2 protocols were not expected to produce
significant differences in mandibular growth changes
(Co-Gn).12 As a result of these similar changes in
maxillary and mandibular anteroposterior positioning,
changes in maxillomandibular relationship were also
similar between the groups.
Accordingly, changes in the growth pattern be-
tween the groups were also similar, as expected. Usu-
ally, changes in the growth pattern between extraction
and nonextraction patients do not show significant
changes12-14; therefore, one would not expect that differ-
ences would be apparent between these 2 protocols.
American Journal of Orthodontics and Dentofacial Orthopedics Janson et al 33
Volume 132, Number 1

Table III. Comparison between treatment changes in groups 1 and 2 (T2-T1) with t test
Group 1 (n ⫽27) Group 2 (n ⫽ 27)

Variables Mean SD Mean SD P

Treatment time (y) (years) 2.64 0.84 2.40 0.42 .192

Maxillary component
SNA (°) ⫺0.39 1.89 ⫺0.78 1.61 .424
Co-A (mm) 1.06 2.68 ⫺0.10 2.80 .123
Mandibular component
SNB (°) 0.48 2.05 0.86 1.36 .429
Co-Gn (mm) 4.04 4.32 3.76 3.89 .805
Maxillomandibular relationship
ANB (°) ⫺0.87 1.56 ⫺1.63 1.20 .050
Diff. Mx-Md (mm) 2.98 2.92 3.86 2.66 .251
Growth pattern
SN.GoGn (degrees) ⫺0.79 2.40 ⫺0.72 2.01 .907
FMA (°) ⫺1.15 2.28 ⫺0.65 2.84 .476
LAFH (mm) 2.62 2.32 2.19 2.64 .535
Posterior dentoalveolar component
Mx6-PTV (mm) 3.76 4.12 2.57 2.92 .226
Mx6-PP (mm) 1.71 1.87 1.56 1.31 .738
Md6-PTV (mm) 3.62 4.48 4.39 2.83 .454
Md6-MP (mm) 2.44 1.69 2.63 1.60 .675
Anterior maxillary dentoalveolar component
Mx1.NA (degrees) ⫺2.76 11.06 ⫺4.49 7.96 .511
Mx1-NA (mm) ⫺2.11 3.15 ⫺2.33 2.67 .788
Mx1.PP (degrees) ⫺2.37 11.34 ⫺5.51 8.30 .251
Mx1-Aperp (mm) ⫺2.03 3.03 ⫺2.78 2.82 .347
Mx1-PP (mm) 0.43 2.50 0.62 1.64 .744
Anterior mandibular dentoalveolar component
Md1.NB (degrees) ⫺2.19 4.15 ⫺4.65 6.46 .102
Md1-NB (mm) ⫺0.46 1.19 ⫺2.12 1.68 .000*
Md1.MP (degrees) ⫺2.13 4.72 ⫺4.62 6.45 .112
Md1-Bperp (mm) ⫺0.82 1.37 ⫺2.32 1.77 .001*
Md1-MP (mm) 1.30 1.60 ⫺0.43 2.01 .001*
Soft-tissue component
H.NB (°) ⫺2.32 2.46 ⫺3.88 2.22 .018*
H-Pr (mm) 3.12 2.81 4.38 2.26 .075
H-LL (mm) ⫺0.30 1.07 ⫺0.93 1.54 .085
Skeletal and dentoskeletal asymmetries
MxAsym (mm) 0.41 1.21 0.10 1.50 .398
MdAsym (mm) 0.15 1.17 ⫺0.05 1.26 .539
Mx6Asym (mm) ⫺0.12 0.95 ⫺0.33 1.37 .521
Md6Asym (mm) 1.16 1.36 ⫺0.52 1.54 .000*

Diff, Difference.
*Statistically significant.

Although the horizontal changes in the maxillary
and mandibular molars were similar, they tended to
reflect the mechanics used in each treatment protocol
(Table III). The maxillary molars in group 2 had to
have a greater restriction of forward displacement to
correct the Class II relationship and to allow greater
retraction of the maxillary incisors, proportional to the
amount of retraction of the mandibular incisors.15
Concurrently, the mandibular molars in this group had
to have more forward displacement to facilitate correc-
tion of molar Class II relationships.16-21
The maxillary incisors tended to show greater
retraction and palatal inclination in group 2, propor-
tional to the significantly greater retraction of the
mandibular incisors1,12-14,22 (Table III). However, the
amounts of the changes were not large enough to be
statistically significant between the groups. The great
variability (large standard deviations) in the amount of
retraction in the groups also contributed to this lack of
significant differences. Vertically, the changes in the
maxillary incisors were similar.
Our results demonstrate a significantly smaller lin-
34 Janson et al
ear retraction of the mandibular incisors in patients
treated with extraction of 3 premolars when compared
with those treated with 4 extractions, as expected1,23-25
(Table III). However, the lingual inclination was simi-
lar between the groups. Vertically, the mandibular
incisors in group 2 had statistically greater restriction of
their vertical development. This might reflect poor
vertical control of the mandibular incisors in the 3-pre-
molar extraction protocol and require further specific
investigation.
Changes in soft tissues were significantly greater in
group 2 (H.NB), reflecting the significantly larger
mandibular incisor linear retraction and the nonsignifi-
cantly larger lingual inclination of these teeth and of the
maxillary incisors’ retrusion and palatal inclination,
confirming previous expectations.1,23-25 This means
that retraction of the upper lip in group 2 was signifi-
cantly greater than in group 1. Although retraction of
the lower lip was greater in group 2, it was not
statistically significant. It can be speculated that the
changes in upper lip retraction were statistically greater
in group 2, whereas the maxillary incisors’ retraction
amounts (angular and linear) were not significantly
larger because of the greater variability (large standard
deviations) in the amount of maxillary incisor retraction
(Table III). Because no other clinical evaluation of the
treatment outcomes was conducted, it could be ques-
tionable whether this statistically significant greater
change in group 2 is clinically relevant. According to
previous reports, statistically significant soft-tissue
changes are usually clinically relevant.26-30 Changes in
H-Pr and H-LL were not significantly different, despite
also showing greater soft-tissue retraction in group 2.
Regarding the asymmetry changes, only the amount
of asymmetry between the right and left mandibular
molars increased significantly more in group 1 than in
group 2, probably because the mechanics tended to
accentuate the asymmetric positioning of these teeth
over the mandibular bone.31 On the mandibular Class I
side, in the 3-premolar extraction protocol, when a
premolar has been extracted, despite efforts to preserve
anchorage, some mesial drifting of the first molar might
occur; this accentuates the already existing anteroposterior
asymmetry between the mandibular molars. The opposite
occurred in the 4 premolar extraction protocol; ie, the
initial asymmetry tended to decrease because of the
greater use of anterior diagonal elastics and Class II
elastics on the Class II side, to correct the anteroposterior
molar relationship. As the mandibular molar on the Class
II side drifted mesially consequent to Class II elastics, the
asymmetry slightly decreased. These different treatment
protocols could not differently influence the asymmetries
of the maxilla, the mandible, or the maxillary molars.
American Journal of Orthodontics and Dentofacial Orthopedics
July 2007
These results are useful for the clinician in deciding
whether to treat a Class II subdivision malocclusion
with a 3- or 4-premolar extraction protocol. Generally,
an asymmetric extraction protocol will provide better
occlusal treatment success than a symmetric extraction
protocol.1 When the patient’s profile does not allow
significant retraction, a 3-premolar extraction protocol
would also be a better alternative esthetically.
CONCLUSIONS
The null hypothesis was rejected because the 3-pre-
molar extraction protocol had the following differences
in relation to the 4-premolar extraction protocol.
1. Smaller mandibular incisor and soft-tissue retrac-
tions.
2. Greater mandibular incisor extrusion.
3. Greater increase in left-to-right anteroposterior
mandibular first molar degree of asymmetry.
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Class II subdivision treatment success rate with symmetric and
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thop 2003;124:257-64.
2. Alavi DG, BeGole EA, Schneider BJ. Facial and dental arch
asymmetries in Class II subdivision malocclusion. Am J Orthod
Dentofacial Orthop 1988;93:38-46.
3. Grainger RM. Orthodontic treatment priority index. Washington
DC: National Center for Health Statistics, Education and Wel-
fare; 1967.
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