ORIGINAL ARTICLE

Class II treatment efficiency in maxillary

premolar extraction and nonextraction
protocols
Guilherme Janson,a Sérgio Estelita Cavalcante Barros,b Marcos Roberto de Freitas,a
José Fernando Castanha Henriques,a and Arnaldo Pinzanc
Bauru, Brazil

Introduction: In this study, we compared the efficiency of nonextraction and 2-maxillary-premolar-extraction

protocols in complete Class II malocclusion treatment. Methods: A sample of 112 records from patients with
complete Class II malocclusion was divided into 2 groups with the following characteristics: group 1,
comprising 43 patients treated nonextraction with an initial mean age of 12.63 years; and group 2, comprising
69 patients treated with extraction of 2 maxillary premolars with an initial mean age of 13.91 years. To
compare the efficiency of each treatment protocol, the initial and final occlusal statuses were evaluated on
dental casts with the peer assessment rating (PAR) index, and the treatment time of each group was
calculated from the clinical charts. Treatment efficiency was calculated by the ratio between the percentage
of PAR reduction and the treatment time. PAR scores, treatment times, and treatment protocols’ efficiencies
of the groups were compared with the t test. Results: The 2-maxillary-premolar-extraction protocol had a
smaller final PAR score, a greater percentage of PAR reduction, and greater treatment efficiency than the
nonextraction protocol of complete Class II malocclusion. Conclusion: The 2-maxillary-premolar-extraction
protocol has greater treatment efficiency than the nonextraction protocol of complete Class II malocclusion.
(Am J Orthod Dentofacial Orthop 2007;132:490-8)

t is known that treatment protocol and malocclusion ment with removable appliances and more patient com-

I severity can influence the results, the duration, and,

consequently, the efficiency of orthodontic treat-
ment.1-9 Because malocclusion severity is an inherent
characteristic that cannot be controlled, efforts have been
made to evaluate the influence of treatment protocol on
the efficiency of orthodontic treatment.3,10,11 Efficiency is
defined as the capacity of producing the best results with
the least time expense.12 It was demonstrated that com-
plete Class II malocclusion treatment with 2 maxillary
premolar extractions produces a better occlusal success
rate than the 4-premolar-extraction protocol,6 because
obtaining a Class I molar relationship in the 4-premolar-
extraction protocol requires more anchorage reinforce-
From the Department of Orthodontics, Bauru Dental School, University of São
Paulo, Bauru, Brazil.
a
Professor.
b
Graduate student.
c
Associate professor.
Based on research by the second author in partial fulfillment of the require-
ments for the degree of master of science 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, January 2005; revised and accepted, October 2005.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.10.031
490
pliance than maintaining Class II molar relationship in the
2-maxillary-premolar-extraction protocol.2,5,6,13,14 Treat-
ment time is also shorter in the 2-maxillary-premolar
protocol than in the 4-premolar-extraction protocol15 be-
cause molar relationship correction, inherent to nonextrac-
tion and 4-premolar-extraction protocols, is considered to
increase Class II treatment time.3,8,11,16 According to this
rationale, it could be speculated that probably a 2-premo-
lar-extraction protocol also has a better occlusal success
rate and a shorter treatment time than a nonextraction
protocol in complete Class II malocclusion patients. Al-
though treatment results and treatment times have been
compared between treatment protocols, the amounts of
change in a time period have not been related to each other
to evaluate treatment efficiency.
The purpose of this study was to test the following
null hypothesis: complete Class II malocclusion treatment
efficiency is similar in nonextraction and 2-maxillary-
premolar-extraction protocols. Therefore, occlusal results,
treatment times, and efficiency index values were com-
pared between the 2 groups treated with these protocols.
MATERIAL AND METHODS
The sample was retrospectively selected from the
files of the Department of Orthodontics at Bauru Dental
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 4
School, University of São Paulo, Brazil; the files
include 3592 documented and treated patients. Records
and the initial and final dental study models of all
patients who initially had complete bilateral Angle
Class II malocclusion (molar relationship) and were
treated without extractions or with 2 maxillary premo-
lar extractions and standard fixed edgewise appliances
were selected and divided into 2 groups. Sample
selection was based exclusively on the initial antero-
posterior (AP) dental relationship, regardless of any
other dentoalveolar or skeletal characteristic. Addition-
ally, the patients selected had all permanent teeth up to
the first molars and no dental anomalies of number,
size, and form. Group 1 consisted of 43 patients (21
male, 22 female) treated nonextraction at an initial
mean age of 12.63 ⫾ 1.45 years (range, 9.39-16.03
years). Thirty-six of these patients had Class II Division
1 malocclusions, and 7 had Class II Division 2 maloc-
clusions. Group 2 consisted of 69 patients (38 male, 31
female) treated with extraction of 2 maxillary first
premolars at an initial mean age of 13.91 ⫾ 2.71 years
(range, 9.42-27.08 years). Fifty-one of these patients
had Class II Division 1 malocclusions, and 18 had
Class II Division 2 malocclusions.
Orthodontic mechanics included fixed edgewise
appliance, with 0.022 ⫻ 0.028-in conventional brackets
and the usual wire sequence characterized by an initial
0.015-in Twist-Flex or a 0.016-in Nitinol, followed
by 0.016, 0.018, 0.020, and 0.021 ⫻ 0.025 or 0.018 ⫻
0.025-in stainless steel wires (all from 3M Unitek,
Monrovia, Calif). Deepbite was corrected with accen-
tuated and reverse curve of Spee. In the 2-maxillary-
premolar-extraction patients, the anterior teeth were
retracted en masse with a rectangular wire and elastic
chains for overjet and Class II canine correction.
Extraoral headgear was used to correct the Class II AP
relationship in the nonextraction group, whereas, in the
extraction group, an extraoral appliance was used to
reinforce anchorage and maintain the Class II molar
relationship. When necessary, Class II elastics were
used in the nonextraction group to help obtain a Class
I molar relationship; in the extraction group, this
procedure was used to help maintain a Class II molar
relationship.
The patients’ records were used to determine initial
age (IAge), sex, date of treatment onset, date of
treatment completion, and total treatment time (TT).
During this procedure, it was observed that 21 of the 43
patients (48.8%) treated without extractions received
2-phase treatment and used the combined headgear-
activator appliance for 11.2 ⫾ 6 months before treat-
ment with a fixed appliance. On the other hand, 22 of
the 69 patients (31.8%) treated with extractions of
Janson et al 491
maxillary premolars had the extractions because of the
unsuccessful attempt of Class II malocclusion treatment
without extractions. Because the nonextraction group’s
2-phase treatment and the extraction group’s delayed
extractions could influence the occlusal results and
TT,17-23 the nonextraction patients were divided into 1-
and 2-phase treatment subgroups (subgroups 1A and
1B), whereas the extraction patients were divided into
immediate-extractions and delayed-extractions sub-
groups (subgroups 2A and 2B). These subgroups were
also compared to investigate whether 2-phase treatment
and delayed extractions affect the results.
The peer assessment rating (PAR) index24 was
calculated on the pretreatment and posttreatment study
models of each patient, according to the American
weightings suggested by DeGuzman et al.25 Initial and
final occlusal characteristics were ranked by scores for
molar and premolar AP relationship, overjet, overbite,
midline, crossbite, and crowding to quantify the initial
malocclusion severity (I-PAR), the occlusal treatment
results (F-PAR), and the percentage of PAR reduction
(PcPAR),3,7,26 which is a better estimate of occlusal
improvement.10
Because the PAR index analyzes a set of occlusal
characteristics at the same time and does not discrimi-
nate the participation degree of each in the total score,
the posttreatment scores obtained for each PAR com-
ponent were individually compared to determine the
success rate achieved. Therefore, the PAR score at the
end of treatment was again separated into its several
components to allow an individual evaluation.
The treatment efficiency index (TEI) was evaluated by
the relationship between PcPAR and TT in months,
expressed as TEI ⫽ PcPAR/TT. The TEI increased when
a greater PcPAR was associated with a shorter TT.
Initial and final PAR scores were recalculated by
the same examiner (S.E.C.B.) in the pretreatment and
posttreatment study models of 30 randomly selected
patients. The casual error was estimated by Dahlberg’s
formula (Se2 ⫽ ⌺d2/2n), where S2 is the error variance
and d is the difference between the 2 determinations of
the same variable; the systematic error was calculated
with dependent t tests, at P ⬍.05.27,28
Statistical analyses
Compatibility of the groups regarding the propor-
tions of Class II Divisions 1 and 2 malocclusions and
sexes was evaluated with chi-square tests. T tests were
used to compare the groups regarding IAge, I-PAR,
F-PAR, PcPAR, TT, and TEI. Because there was a
statistically significant difference in the IAges that
could influence F-PAR and TT,3,18,20,22,29-32 some pa-
tients were eliminated from both groups to match the
492 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2007

Table I. Results of independent t test between groups 1 and 2

Group 2 (n ⫽ 69)
Group 1 (n ⫽ 43) (maxillary premolar
(nonextraction) extractions)

Variable Mean SD Mean SD df P

IAge 12.63 1.45 13.91 2.71 110 .0053*

I-PAR 24.32 7.67 23.95 7.40 110 .8008
F-PAR 5.67 5.62 2.42 2.88 110 .0001*
PcPAR 72.69 31.38 88.87 13.91 110 .0002*
TT 30.14 9.74 26.99 10.16 110 .1078
TEI 2.95 1.32 3.78 1.27 110 .0013*

*Statistically significant at P ⬍.05.

Table II. Results of independent t test between groups 1 and 2 with comparable initial ages
Group 2 (n ⫽ 58)
Group 1 (n ⫽ 36) (maxillary premolar
(nonextraction) extractions)

Variable Mean SD Mean SD df P

IAge 12.92 1.09 13.21 1.29 92 .2639

I-PAR 24.08 7.93 23.91 7.18 92 .9151
F-PAR 5.27 5.80 2.37 2.88 92 .0017*
PcPAR 73.78 33.33 88.94 14.28 92 .0030*
TT 29.72 9.65 26.72 10.53 92 .1700
TEI 2.78 1.52 3.74 1.39 92 .0022*

*Statistically significant at P ⬍.05.

IAges, and the groups were compared again with the t
test. Descriptive statistical analysis was used to show
the patient distribution according to the F-PAR. The
occlusal results obtained for each component of the
PAR were individually compared between the groups
with the Mann-Whitney U-test. A nonparametric test
was used because the values of each PAR component
did not have normal distribution, according to the
Kolmogorov-Smirnov test.33
To investigate whether 2-phase treatment or de-
layed extractions had influenced F-PAR and TT, the
following comparisons were made: group 1 and sub-
groups 2A and 2B were compared with each other with
ANOVA, followed by Tukey tests; subgroup 1B was
compared with group 2, and subgroups 1A and 2A were
compared with t tests.
RESULTS
The I-PAR and F-PAR did not have significant
systematic errors, and the casual errors were within
acceptable levels (Dahlberg: I-PAR ⫽ 0.8062, F-PAR ⫽
0.5916). The groups were similar regarding the
proportion of Class II Divisions 1 and 2 malocclusion
types and sexes (␹2 ⫽ 1.4696 and P ⫽ .2254; ␹2 ⫽
0.4131 and P ⫽ .5204, respectively). IAge, Pc PAR,
and TEI were statistically greater and the F-PAR was
statistically smaller for the extraction group (the
smaller the F-PAR score, the greater the occlusal
success rate) (Table I). Similar results were obtained
when IAge was matched in the groups (Table II). At the
posttreatment stage, the extraction group had a greater
percentage of patients with PAR scores equal to zero
and a smaller PAR range (Table III). When several
occlusal characteristics of the F-PAR index were indi-
vidually compared between the groups, a better AP
relationship of the buccal occlusion was observed in the
extraction group (Table IV). The immediate-extractions
subgroup had a statistically shorter TT and a higher TEI
than the delayed-extractions subgroup and the nonex-
traction group. The F-PAR score and the PcPAR were
similar between the immediate and the delayed-extrac-
tions subgroups, and statistically greater and smaller in
the nonextracion group, respectively (Table V). The
2-phase nonextraction subgroup had a greater F-PAR
score, a smaller PcPAR, and a smaller TEI than the
extraction group (Table VI). A statistically longer TT
and a smaller TEI were found for the 1-phase nonex-
traction subgroup compared with the immediate-extrac-
tions subgroup (Table VII).
American Journal of Orthodontics and Dentofacial Orthopedics Janson et al 493
Volume 132, Number 4

Table III. Descriptive analysis of the patients’ percentages in groups 1 and 2 according to F-PAR
F-PAR (score) 0 2 3 4 5 6 7 8 9 10 11 12 14 15 16 18 20

Cumulative %, group1
(nonextraction) 30.2 37.2 41.8 51.1 53.4 62.7 67.4 72 81.3 81.3 86 86 88.3 90.6 95.3 97.6 100
Cumulative %, group 2
(maxillary premolar
extractions) 44.9 62.3 65.2 81.1 86.9 89.8 94.2 95.6 95.6 98.5 98.5 100 100 100 100 100 100

Table IV. Results of the comparison of the F-PAR individual components between groups 1 and 2 (Mann-Whitney
U test)
Group 1 (n ⫽ 43) (nonextraction) Group 2 (n ⫽ 69) (maxillary premolar extractions)

Variable Mean rank Mean rank Z P

AP 64.97 51.21 ⫺2.180 .0292*

OVJ 61.86 53.15 ⫺1.379 .1679
OVB 62.04 53.04 ⫺1.426 .1536
ML 57.60 55.81 ⫺0.284 .7762
CB 60.30 54.13 ⫺0.978 .3280
C 55.48 57.11 ⫺0.257 .7969

OVJ, overjet; OVB, overbite; ML, midline; CB, crossbite; C, crowding.

*Statistically significant at P ⬍.05.

Table V. Results of ANOVA and Tukey tests between group 1 and subgroups 2A and 2B
Subgroup 2A (n ⫽ 47) Subgroup 2B (n ⫽ 22)
(maxillary premolar (maxillary premolar
Group 1 (n ⫽ 43) extractions, immediate extractions, delayed
(nonextraction) extractions) extractions) ANOVA

Variable Mean SD Mean SD Mean SD F P

I-PAR 24.32a 7.67 24.34a 7.47 23.13a 7.35 0.223 .8002

F-PAR 5.67a 5.62 2.80b 3.13 1.59b 2.08 8.82 .0002*
PcPAR 72.69a 31.38 87.41b 14.40 91.99b 12.56 7.27 .0010*
TT 30.14a 9.74 23.60b 6.31 34.21a 12.93 11.37 .0000*
TEI 2.69a 1.43 3.95b 1.26 3.08a 1.28 10.31 .0000*

Different letters represent statistically significant differences.

*Statistically significant for P ⬍.05.

DISCUSSION ference in the final occlusal success rate between these

Our subjects were selected primarily on the basis of
a complete bilateral Class II malocclusion, independent
of the associated cephalometric skeletal characteristics.
Since both groups were similarly chosen, it could be
expected that these characteristics would be evenly
distributed between them. Usually, it is not the skeletal
characteristics of a Class II malocclusion that primarily
determine whether it should be treated with or without
2 maxillary premolar extractions but, rather, the pa-
tient’s development stage, because maxillary-premolar-
extraction treatment has been preferentially used in
nongrowing Class II patients.2,14,34-37 Nevertheless, the
similarity of the malocclusion types and the initial
malocclusion severity points toward cephalometric
compatibility of the groups.38 Additionally, the primary
objective was to investigate whether there was a dif-
2 treatment protocols. Further studies on the influence
of skeletal pattern on our results are being conducted.
At the beginning of treatment, the groups were
similar, except for IAge (Table I). Even though a
younger age would favor Class II treatment of the
nonextraction group,31,39 the extraction group had more
favorable occlusal results (Table I). Nevertheless, to
eliminate any concern, the groups were divided into
subgroups with matching IAges, which were compared
with the t test (Table II).
The F-PAR and the PcPAR results had statistically
significant differences between groups 1 and 2, with
more favorable results for group 2, as shown in Table I.
This demonstrates that Class II malocclusion treatment
with extraction of 2 premolars not only allows a better
occlusal success rate, but also produces a greater
494 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2007

Table VI. Results of independent t test between subgroup 1B and group 2

Group 2 (n ⫽ 69)
Subgroup 1B (n ⫽ 21) (maxillary premolar
(nonextraction, 2-phase) extractions)

Variable Mean SD Mean SD df P

I-PAR 26.42 7.84 23.95 7.40 88 .1899

F-PAR 4.95 5.75 2.42 2.88 88 .0078*
PcPAR 77.89 26.69 88.87 13.91 88 .0144*
TT 31.96 10.53 26.99 10.16 88 .0548
TEI 2.74 1.42 3.67 1.33 88 .0067*

*Statistically significant at P ⬍.05.

Table VII. Results of independent t test between subgroups 1A and 2A

Subgroup 2A (n ⫽ 47)
(maxillary premolar
Subgroup 1A (n ⫽ 22) extractions, immediate
(nonextraction, 1-phase) extractions)

Variable Mean SD Mean SD df P

I-PAR 22.31 7.11 24.34 7.47 67 .2917

F-PAR 6.36 5.53 2.80 3.13 67 .0011*
PcPAR 67.73 35.19 87.41 14.40 67 .0015*
TT 28.40 8.82 23.60 6.31 67 .0121*
TEI 2.65 1.48 3.95 1.26 67 .0003*

*Statistically significant at P ⬍.05.

proportion of changes in the initial improper dental
relationships. Results of the subgroups’ comparison
with matching IAges showed a similar tendency of the
groups (Table II). The better occlusal success rate of
group 2 is also shown by the greater percentage of
patients with a PAR score equal to zero in relation to
group 1 at the end of treatment. According to Rich-
mond et al24 and Buchanan et al,40 when the PAR index
at the end of treatment is smaller than or equal to 5, the
occlusion is considered almost perfect. The extraction
group had 86.9% and the non-extraction group had 53.4%
of the patients in this correction range (Table III).
To determine which PAR components had primar-
ily contributed to the occlusal success rate difference
between the groups, they were individually compared.
The extraction group had a statistically smaller post-
treatment score and, consequently, a greater occlusal
success rate of molar and premolar AP relationship
correction than group 1. This showed that AP relation-
ship correction was the primary component that con-
tributed to the poorer occlusal results in group 1 (Table
IV). This seems logical because nonextraction Class II
treatment requires twice as much anchorage reinforce-
ment and consequently more patient compliance to
achieve a molar Class I relationship than the 2-maxillary-
premolar-extraction protocol to maintain the Class II
molar relationship.13 Therefore, these results support the
findings of other studies that suggest that treatment
difficulty increases when a full-cusp Class II molar
relationship must be completely corrected.2,4-6,8,9,13,14
The following paragraphs theoretically illustrate the
greater difficulty of the nonextraction approach.
Treatment of complete Class II malocclusions with
extraction of only 2 maxillary premolars requires an-
chorage reinforcement to avoid mesial movement of the
posterior segment during retraction of the anterior
teeth. Because the average mesiodistal diameter of
premolars is 7 mm, the anterior teeth should therefore
be distalized through this distance.13 Appliances that
provide this anchorage reinforcement are primarily
extraoral, thus requiring patient compliance for a suc-
cessful treatment result.
In complete Class II therapy without premolar
extractions, the need for anchorage reinforcement is
even greater, because the posterior segment must be
distalized 7 mm to achieve a Class I molar relationship
at the end of treatment.41,42 Afterwards, all anterior
teeth must be distalized 7 mm (or “space units”13),
corresponding to the distalization of the posterior seg-
ment. Therefore, there will be 7 mm of distalization of
the posterior segment added to 7 mm of the anterior
segment, for a total of 14 mm of distalization for both
posterior and anterior segments; this is twice the
amount required for Class II correction with extraction
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 4
of only the maxillary premolars.13 Consequently, the
need for anchorage reinforcement in those patients is
twice as great, and treatment success depends even
more on patient compliance.
These explanations obviously illustrate only stati-
cally the amount of required anchorage and patient
compliance for the various situations. Nevertheless,
such mechanisms of correction should be associated
with growth, which might help in achieving a satisfac-
tory occlusal outcome.30,31,43-46 If the patient is still
growing, the probability of success of the mentioned
protocols is considerably increased because the ex-
traoral appliances for anchorage reinforcement not only
distalize the maxillary teeth, but also redirect maxillary
growth, restricting its anterior displacement, which will
be valuable for Class II correction. Moreover, mandib-
ular growth, as well as its normal anterior displacement,
will increase the probability of correction of the AP
discrepancy.31,43,47 This growth potential is even more
important in Class II patients who receive nonextrac-
tion treatment because, as previously shown, they will
require more distalization of the maxillary teeth; this
might be reduced by an association with redirection of
growth of the apical bases.31,45,47 Therefore, the great
limitation of nonextraction Class II treatment in adults
and nongrowing patients can be noticed.
TT was similar between the 2 groups (Tables I and
II). However, because 31.8% of the patients in the
extraction group had delayed extractions, which can
influence treatment time, the group was subdivided.
The TEI was defined as the ratio between PcPAR
and TT (TEI ⫽ PcPAR/TT), creating a TEI that
allowed a true and objective comparison of treatment
efficiency. The 2-maxillary-premolar-extraction group
had a statistically greater TEI than the nonextraction
group because the occlusal changes were greater during
a similar treatment time period (Tables I and II).
When the extraction subgroups of immediate ex-
tractions and delayed extractions (subgroups 2A and
2B) were compared with group 1, both subgroups had
statistically smaller F-PAR and greater PcPAR values
than group 1 (Table V). This suggests that even the
patients previously assigned to nonextraction treatment,
who had delayed extractions because of deficient com-
pliance, complied with the lesser anchorage require-
ments of the 2-maxillary-premolar-extraction proto-
col13 and had a better occlusal success rate than the
compliant patients of the nonextraction approach.
TT in the immediate-extractions subgroup was
statistically smaller than in group 1 and similar between
the delayed-extractions subgroup and group 1 (Table
V). This demonstrates that it was the delayed-extraction
patients that accounted for a similar treatment time in
Janson et al 495
groups 1 and 2 when directly compared. Therefore,
when the 2-maxillary-premolar-extraction protocol is
immediately undertaken, it has a statistically shorter TT
than the nonextraction protocol. These results contra-
dict others that associated the number of extractions
with increased TT.3,7,8,10,16,48,49 However, in these
studies, the malocclusions were not homogeneous in
malocclusion type and severity.7,8,10,16,48,49 Conse-
quently, the shorter TT of the nonextraction patients
might reflect simpler treatments for localized problems;
extractions, in contrast, tend to be strongly associated
with the treatment of more marked discrepancies3,7,10,16
(which require more extensive tooth movements). It is
reasonable to speculate that treatment of a Class I
malocclusion without extractions is faster than that with
extractions, since retraction of the anterior teeth de-
mands additional time. Also, it would be expected that
nonextraction treatment of Class I malocclusions would
have a shorter TT than nonextraction treatment of Class
II malocclusions because of the additional time to
correct the AP relationship. Therefore, the influence of
the number of extractions on TT requires investigation
with similar malocclusion type and severity and with
different treatment protocols to assess the actual con-
tribution of the extractions on TT. In this study, with
these controlled parameters, it was shown that the
immediate-extraction protocol of 2 maxillary premolars
had even a statistically shorter TT than the nonextrac-
tion approach.
As a consequence of a statistically shorter TT of the
immediate-extractions subgroup, its treatment effi-
ciency was also significantly greater than the nonex-
traction group with a higher value than the extraction
group. Furthermore, the smaller occlusal success rate
(greater F-PAR) of the nonextraction group also ac-
counted for the smaller TEI observed in this group
(Table V). Therefore, it can be concluded that the
difficulty in correcting the Class II molar relationship
was the factor that most contributed to the smaller TEI
of the nonextraction protocol because the failure to
achieve this treatment goal significantly compromised
its TT and F-PAR. The TEI of the delayed-extractions
subgroup was similar to the nonextraction group even
though it had a greater PcPAR. This was because the
TT of this group was longer, although not significantly
in relation to the nonextraction group.
The claim that 2-phase Class II malocclusion treat-
ment produces better orthodontic results than those
accomplished in only 1 phase finds support in some
studies,23,50,51 although several controversies exist
about this subject.19,21,52-54 Because, in the nonextrac-
tion group in 21 of 43 patients (subgroup 1B), treatment
was divided into orthopedic and orthodontic phases, it
496 Janson et al
was speculated that this subgroup could have achieved
occlusal success similar to that of the extraction group
and that the less satisfactory result of the nonextraction
group was due to the nonextraction subgroup treated in
only 1 phase (subgroup 1A). However, results obtained
with the 2-phase nonextraction treatment showed a
smaller occlusal result success rate (greater F-PAR) and
a smaller PcPAR than the extraction treatment (Table
VI). Therefore, these results do not support the hypoth-
esis that 2-phase treatment significantly influences
Class II treatment results and evidences the difficulty of
molar relationship correction as the factor that most
compromised the nonextraction treatment re-
sults.2,4,6,8,9,13,14,55
TT in the 2-phase nonextraction treatment was
similar to the extraction group, because the delayed-
extraction subgroup contributed to prolong TT, as
already discussed (Table VI). Reports stating that
2-phase Class II malocclusion treatment increases TT
suggest that this treatment protocol would have influ-
enced TT of the nonextraction group.7,16,17,19,21,53
However, the 1-phase nonextraction subgroup had a
significantly longer TT than the immediate-extractions
subgroup (Table VII). Thus, the longer TT of the
nonextraction group cannot be attributed to the 2-phase
subgroup. Therefore, the greater difficulty imposed by
the attempt to correct the Class II molar relationship in
the nonextraction group was the factor that most
contributed to increase TT.2,8,11,16,17
Despite similar TTs, the TEI of the extraction group
was statistically greater than that of the 2-phase non-
extraction subgroup (Table VI), alike results of the
groups comparison (Table II).
The compliance necessary for treatment success
varies according to patient age and malocclusion sever-
ity.4,9,30,31 Compliance, age, and malocclusion severity
are clinical variables that cannot be controlled by the
operator, because they are inherent to the patient.
Because 2-maxillary-premolar-extraction Class II mal-
occlusion treatment reduces by half the compliance
required from the patient,13 our findings show that a
greater occlusal success rate and a shorter TT can be
expected with this protocol, increasing treatment pre-
dictability, even when used in patients with reduced
growth potential or severe malocclusions. In spite of
this evidence, a certain reluctance persists in the liter-
ature for 2-maxillary-premolar-extraction Class II treat-
ment in growing patients, restricting its application to
nongrowing patients.2,34-37,56 This approach appears to
be a conditioned attitude rather than a decision based on
scientific evidence, since orthodontic treatment results
during the growth period are predominantly dentoalve-
olar regardless of orthodontic technique, treatment
American Journal of Orthodontics and Dentofacial Orthopedics
October 2007
protocol, or appliance type.19,57-63 Therefore, there is
evidence to justify the 2-maxillary-premolar-extraction
protocol during the pubertal growth period because
it requires less patient compliance.2,5,6,13,14 Conse-
quently, moderate patient compliance with extraoral
headgear or functional appliance can be insufficient to
successfully treat by nonextraction a complete Class II
malocclusion, but it can be suitable for a 2-maxillary-
premolar-extraction protocol.4,9
Because treatment success is an expectation that
invariably falls on the orthodontist’s clinical conduct,64
and noncompliance is not always accepted by the
parents or the patient as an excuse for unsatisfactory
results or increased TT, the treatment protocol choice
should be based, preferably, on treatment efficiency.
CONCLUSIONS
According to these results, the null hypothesis was
rejected because Class II malocclusion treatment with 2
premolar extractions showed a better occlusal success
rate, in a shorter TT, with consequently greater treat-
ment efficiency than the nonextraction protocol. The
less satisfactory results of the nonextraction Class II
treatment were related primarily to the smaller AP
relationship correction success, because of the greater
patient compliance required with anchorage reinforcing
appliances.
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