ORIGINAL ARTICLE

Efficiency of Class II subdivision malocclusion

treatment with 3 and 4 premolar extractions
Guilherme Janson,a Taiana Baldo,b Daniela Garib,c Se
rgio Estelita Barros,d Raquel Silva Poletto,b
and Patricia Bittencourt dos Santosb
Bauru, S~ao Paulo, and Porto Alegre, Rio Grande do Sul, Brazil

Introduction: In this study, we compared the efficiency of Class II subdivision malocclusion treatment with sym-
metric and asymmetric extractions. Methods: A sample of 71 patients with complete Class II subdivision maloc-
clusion was selected: group 1 consisted of 40 patients treated with 4 premolar extractions with an initial mean
age of 13.37 years, and group 2 had 31 patients treated with 3 premolar extractions (2 maxillary premolars
and 1 mandibular premolar on the Class I side) with an initial mean age of 14.44 years. To compare the efficiency
of each treatment protocol, the initial and final occlusal results were evaluated on dental casts with the Peer
Assessment Rating occlusal index, and time spent in treatment was calculated from the clinical charts. The
amounts of initial and final midline deviation and improvement of midline deviation correction were also evalu-
ated. Efficiency was calculated as the rate between occlusal improvement by the treatment time. The groups
were compared with t and Mann-Whitney tests. Results: The results showed that group 2 had a significantly
smaller final amount of midline deviation and a greater correction of midline deviation. Conclusions: Treatment
efficiency of type 1 Class II subdivision malocclusions with 3 or 4 premolar extractions is similar. However, treat-
ment with 3 premolar extractions provides a better occlusal success rate. (Am J Orthod Dentofacial Orthop
2016;150:499-503)

C
lass II subdivision malocclusion can be classified
in 2 types. Type 1 is characterized by distal posi-
tioning of the mandibular first molar on the Class
II side—in this type, the maxillary midline is coincident
with the midsagittal plane, and the mandibular midline
is deviated to the Class II side in a frontal view, Type 2
is characterized by mesial positioning of the maxillary
first molar on the Class II side—in this type, the maxillary
a
Professor and head, Department of Orthodontics, Bauru Dental School, Univer-
sity of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
b
Postgraduate student, Department of Orthodontics, Bauru Dental School,
University of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
c
Associate professor, Department of Orthodontics, Bauru Dental School and Hos-
pital for Rehabilitation of Craniofacial Anomalies, University of S~ao Paulo, Bauru,
S~ao Paulo, Brazil.
d
Associate professor, Department of Orthodontics, Federal University of Rio
Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Based on research submitted by Taiana Baldo in partial fulfillment of the require-
ments for the degree of MSc in orthodontics at Bauru Dental School, University
of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
Address correspondence to: Guilherme Janson, Department of Orthodontics,
Bauru Dental School, University of S~ao Paulo, Alameda Oct
avio Pinheiro Brisolla
9-75, Bauru, SP 17012-901, Brazil; e-mail, jansong@travelnet.com.br.
Submitted, July 2015; revised and accepted, February 2016.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. All rights
reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.02.028
midline is deviated to the Class I side, and the mandib-
ular midline is coincident with the midsagittal plane.1,2
Several investigations have focused on the efficiency of
the treatment protocols in the correction of different
malocclusions.3-6 Efficiency consists in the achievement
of the best results in the shortest time.6,7 It has already
been demonstrated that type 1 Class II subdivision
malocclusions1 treated with 3 premolar extractions
have a higher occlusal success rate than treatment with
4 premolar extractions, since obtaining a Class I molar
relationship on the Class II malocclusion side in the 4 pre-
molar extraction protocol requires more anchorage rein-
forcement with removable appliances and patient
compliance than maintaining the Class II molar relation-
ship in the 3 premolar extraction protocol on that side.8,9
Treatment time is also shorter in the 2 maxillary premolar
than in the 4 premolar extraction protocol10 in complete
Class II malocclusion correction, because molar relation-
ship correction, inherent to nonextraction and 4 premolar
extraction protocols, is thought to increase the Class II
treatment time.3,5,11,12 Following this rationale, it could
be speculated that probably a 3 premolar extraction
protocol could also have a shorter treatment time than
a 4 premolar extraction protocol in Class II subdivision
malocclusion patients. Although the results have been
individually compared between treatment protocols in
499
500
Class II subdivision malocclusions, the amounts of
change in a time period have not been related to each
other to evaluate the degree of treatment efficiency.
Thus, the purpose of this study was to test the
following null hypothesis: “Type 1 Class II subdivision
malocclusion treatment efficiency is similar in 4 premo-
lar and 3 premolar extraction protocols.” Therefore,
occlusal results, treatment times, and the efficiency in-
dex were compared between 2 groups treated with these
protocols.
MATERIAL AND METHODS
This study was approved by the ethics in research
committee of Bauru Dental School at the University of
S~ao Paulo in Brazil.
The sample was selected from the files of the Depart-
ment of Orthodontics at Bauru Dental School, University
of S~ao Paulo. Initial and final dental study models of 71
patients who had type 1 Class II subdivision malocclu-
sions (complete Class II on 1 side and Class I on the other
side) and were treated with fixed appliances with a 4 or a
3 premolar extraction protocol were selected.1 The sam-
ple was then divided into 2 groups. Group 1 consisted of
40 patients treated with 4 premolar extractions with an
initial mean age of 13.37 6 1.31 years (range, 10.25-
15.91 years), and group 2 consisted of 31 patients
treated with 3 premolar extractions (2 maxillary premo-
lars and 1 mandibular premolar on the Class I side) with
an initial mean age of 14.44 6 2.83 years (range, 10-
24.25 years). The selection criteria were a full Class II
molar relationship on 1 side and a Class I molar relation-
ship on the other side, and the presence of all permanent
teeth up to the first molars. The additional selection
criteria were (1) no previous orthodontic treatment, (2)
no history of facial trauma that could have altered
growth of the apical bases, and (3) complete orthodontic
records. To select the sample, only the initial anteropos-
terior relationship was considered. No other dentoalveo-
lar or skeletal characteristic was considered.
Orthodontic mechanics included fixed edgewise ap-
pliances, with 0.022 3 0.028-in conventional brackets
and the usual wire sequence characterized by an initial
0.015-in twist flex or a 0.016-in nickel-titanium alloy
archwire, followed by 0.016, 0.018, 0.020, and
0.021 3 0.025 or 0.018 3 0.025-in stainless steel arch-
wires (3M Unitek, Monrovia, Calif). Accentuated and
reverse curve of Spee were used to correct the deepbites.
Rectangular wires and elastic chains were used for en-
masse retraction and to correct overjet and Class II
canine relationship. Extraoral headgear was used to cor-
rect the Class II anteroposterior relationship on the Class
II side and to reinforce anchorage to maintain the Class I
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Janson et al
relationship on the Class I side, in the 4 premolar extrac-
tion protocol. In the 3 premolar extraction protocol, ex-
traoral headgear was used to reinforce anchorage to
maintain the molars in Class II and Class I relationships
on the respective sides. When necessary, Class II elastics
were used in the 4 premolar extraction group to help
obtain a Class I molar relationship on the Class II side,
whereas in the 3 premolar extraction group, this proce-
dure was used to help maintain the original molar
relationship.
To compare the efficiency of the treatment protocol
in each group, the pretreatment and posttreatment
occlusal results were assessed on dental casts using the
Peer Assessment Rating (PAR) occlusal index, according
to the American weightings suggested by DeGuzman
et al,13 and the time spent in the treatment of each group
was calculated from the clinical charts. A form was used
to calculate the PAR index on the pretreatment and
posttreatment study models of each patient (Fig).13,14
The PAR occlusal index evaluates posterior occlusion,
overjet, overbite, dental midline, and crowding.
The amounts of initial and final dental midline devi-
ation and improvement of midline deviation correction
were also evaluated with a caliper (Absolute IP67 model;
Mitutoyo, Kawasaki, Japan).
Treatment efficiency (treatment efficiency index, TEI)
was assessed using an index defined as the rate between
the percentage of occlusal improvement (PCPAR) by the
treatment time (TT) in months, expressed as
TEIPAR 5 PCPAR/TT (Table I). Treatment efficiency in-
creases when a greater percentage of occlusal improve-
ment is associated with a shorter treatment time.
Twenty-two pairs of dental study models were
randomly selected and remeasured by the same exam-
iner (T.B.) a month later. The random errors were calcu-
lated according to Dahlberg's formula15 (Se2 5 Sd2/2n),
where Se2 is the error variance, and d is the difference
between 2 determinations of the same variable. The sys-
tematic errors were estimated with dependent t tests at
P \0.05.
Statistical analysis
Means and standard deviations for each variable were
calculated to enable characterization of the groups.
Normal distributions were verified by the Kolmogorov-
Smirnov test. The results of this test showed that final
malocclusion severity and final midline deviation were
not normally distributed. Therefore, t tests were used
to compare the initial malocclusion severity and age,
amount of malocclusion improvement with treatment,
percentage of improvement, treatment time, treatment
efficiency, initial midline deviation and the change in
Janson et al 501

Occlusal Relationship Discrepancy Degree Score Weight

P Good intercuspidation – Class I, II, or III 0

O
S Antero-posterior relationship Less than half a premolar width 1 2
T Half a premolar width 2
E
R No discrepancy 0
Vertical 2
I Post. open bite of at least 2 teeth and greater than 2mm 1
O
R No crossbite 0
Tendency to crossbite 1
O
C One tooth in crossbite 2
C
L
Two or more teeth in crossbite 3
Transversal 2
U
S
I
Two or more teeth in vestibular crossbite 4
O
N

0 – 3 mm 0
3.1 – 5 mm 1
O Positive 5.1 – 7 mm 2 5
V 7.1 – 9 mm 3
E
More than 9 mm 4
R
J No discrepancy 0
E One or more teeth in top 1
T Negative Only one tooth in crossbite 2 5
Two teeth in crossbite 3
More than two teeth in crossbite 4
No open bite 0
O Open bite smaller than 1mm 1
V Negative Open bite of 1,1 to 2 mm 2 3
E Open bite of 2,1 to 3 mm 3
R
Open bite greater than 4 mm 4
B
I Less than 1/3 of lower incisor crown 0
T More than 1/3 and less than 2/3 of lower incisor crown 1
Positive 3
E More than 2/3 of lower incisor crown 2
More or the same length of lower incisor crown 3

D 0 to 1 mm of displacement 0
I CROWDING
1.1 to 2 mm of displacement 1
S
P SPACING 2.1 to 4 mm of displacement 2 1
L 4.1 to 8 mm of displacement 3
A IMPACTION More than 8 mm of displacement 4
C.
Impacted tooth 5
Coincident or deviated ¼ of incisor width 0
DENTAL MIDLINE Deviated ¼ to ½ of lower incisor crown width 1 3
Deviated more than half of lower incisor crown width 2

Fig. PAR data collection form.

midline deviation between the groups. Intergroup final
malocclusion severity and final midline deviation were
compared with Mann-Whitney tests.
All tests were performed with Statistica software
(release 7; StatSoft, Tulsa, Okla), at P \0.05.
RESULTS
The range of random errors varied from 0.21 (FPAR)
to 0.36 (IPAR), and no variable had a statistically signif-
icant systematic error.
Group 2 had a significantly greater initial age, a
greater change in midline deviation with treatment
and a smaller final midline deviation than did group 1
(Table II).
DISCUSSION
The sample was selected primarily on the basis of a
full Class II molar relationship on one side and a Class
I molar relationship on the other side, independent of
the associated cephalometric skeletal characteristics.
Since the 2 groups were similarly chosen, it could be ex-
pected that these characteristics would be evenly distrib-
uted between them. Their initial malocclusion severity
was similar, as evidenced by the initial PAR index and

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502 Janson et al

treatment efficiency between the groups (Table II). The

Table I. Abbreviations used to represent the variables
only differences were that group 2 had a smaller final
Abbreviation Description midline deviation and greater midline changes than
IPAR Initial PAR index group 1; this was previously demonstrated.8 The smaller
FPAR Final PAR index final midline deviation of group 2 is consequent to the
PCPAR Percentage of improvement of the PAR index
greater improvement in the canine relationship on the
TEIPAR Treatment efficiency index of the PAR index
DIFPAR Amount of improvement of the PAR index Class II side, which is easier to obtain with the 3 premo-
TT Treatment time lar extraction protocol. This is consequent to the lower
IAGE Initial age patient compliance in using Class II intermaxillary elas-
IMD Initial midline deviation tics required with the 3 premolar extraction protocol,
FMD Final midline deviation
giving it a greater occlusal success rate than the 4
CMD Change in midline deviation
premolar extraction protocol.8 However, these
small differences in the final midline deviation and in
Table II. Intergroup comparisons (t and Mann- the changes of the maxillary to mandibular midline de-
Whitney tests) viation between the groups were not enough to demon-
Group 1: Group 2:
strate significant differences in the occlusal results
4 premolar 3 premolar (FPAR, DIFPAR and PCPAR), although they were numer-
extractions extractions ically more favorable for group 2.
(n 5 40) (n 5 31)
Because the 3 premolar extraction protocol was
Variable Mean SD Mean SD P shown to provide a better occlusal success rate, needing
IPAR 21.05 5.83 23.77 8.19 0.106 less patient compliance, it would be expected that
IMD 1.77 1.23 2.23 1.46 0.152 perhaps treatment time would also be shorter with this
IAGE (y) 13.37 1.31 14.44 2.83 0.038* protocol.8 However, no significant difference was found
FPAR 5.60 2.73 4.70 2.03 0.218y
DIFPAR 15.45 6.02 18.58 8.29 0.069
between treatment times of the 2 protocols. The reason
PCPAR 71.86 13.77 77.30 11.77 0.083 may be because the final occlusal status in the 4 premo-
TT (mo) 34.07 12.17 32.80 9.06 0.629 lar extraction protocol is worse, with a greater maxillary
TEIPAR 2.35 0.91 2.54 0.87 0.376 to mandibular midline deviation. If more time was spent
FMD 0.97 0.80 0.51 0.71 0.022*y to completely correct the deviation, then most likely the
CMD 0.79 1.29 1.72 1.56 0.008*
treatment time would be longer, contributing to less
*P \0.05; ynonparametric Mann-Whitney test. treatment efficiency than the 3 premolar extraction
protocol.
initial midline deviation (Table II). Patients with an Consequently, because the percentage of occlusal
incomplete Class II molar relationship on 1 side were improvement and treatment times of the groups were
not included because they could dilute the actual char- similar, the treatment efficiency was also similar. One
acteristics of the Class II subdivision malocclusions. must also consider that the PAR index is not precise
The initial mean age of group 2 was significantly enough to evaluate treatment results. Therefore, prob-
greater than that of group 1 (Table II). Correcting a Class ably if a more precise index that evaluated the maxillary
II anteroposterior relationship becomes more difficult to mandibular midline deviation had been used, a differ-
with age.16,17 Therefore, the age difference between the ence could be demonstrated. The Objective Grading Sys-
groups would favor treatment with the 4 premolar tem of the American Board of Orthodontics is more
extraction protocol (group 1). However, the results specific to evaluate treatment results.18 However, it
showed that group 2 had a better occlusal finish would not allow evaluation of the initial malocclusion
regarding the maxillary to mandibular midline deviation severity, the percentage of occlusal improvement, the
correction, as will be demonstrated. Consequently, this treatment efficiency index, and the amount of occlusal
shows that the age difference did not influence the improvement, which were the main issues to be evalu-
results. This assumption was checked by eliminating the ated. It evaluates only the final treatment results. Also,
5 youngest patients in group 1, which had the most it does not evaluate the initial midline deviation and
patients, and the 2 oldest patients in group 2 to match the change in midline deviation, which were additional
the groups’ ages, and performing the statistical tests variables included to complement the study. For these
again. The results continued to be the same as shown reasons, it was not used in this investigation.
in Table II. Treatment efficiency of type 1 Class II subdivision
There were no significant differences in the occlusal malocclusions was similar whether treated with 4 or 3
results (FPAR, DIFPAR, PCPAR), treatment times, and premolar extractions.8 However, there was a tendency

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Janson et al
for a shorter treatment time and also greater efficiency,
in addition to the significantly better occlusal success
rate (greater improvements in canine relationship on
the Class II side and in midline deviation) provided
with 3 premolar extractions. Additionally, the 3 premolar
extraction protocol is more conservative, requiring fewer
extractions. These factors that positively favor the 3 pre-
molar extraction protocol should be considered when
planning treatment for this type of malocclusion.
These considerations concern the treatment me-
chanics used in this study, without temporary anchorage
devices. The use of temporary anchorage devices may
facilitate the more difficult mechanics of the 4 premolar
extraction protocol in the treatment of type 1 Class II
subdivision malocclusions. Following this rationale, it
is speculated that temporary anchorage would facilitate
even more the easier mechanics of 3 premolar extrac-
tions in these malocclusions. However, this speculation
has yet to be investigated.
CONCLUSIONS
1. The null hypothesis was accepted because treat-
ments of type 1 Class II subdivision malocclusions
with 3 or 4 premolar extractions have a similar
efficiency.
2. However, treatment with 3 premolar extractions
provides a better occlusal success rate.
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