ORIGINAL ARTICLE

Orthodontic treatment time in 2- and

4-premolar-extraction protocols
Guilherme Janson,a Fábio Rogério Torres Maria,b Sérgio Estelita Cavalcante Barros,b
Marcos Roberto de Freitas,c and José Fernando Castanha Henriquesc
Bauru, São Paulo, Brazil

Introduction: The purpose of this study was to compare the treatment times of complete Class II
malocclusions treated with 2- and 4-premolar-extraction protocols. Methods: Ninety-seven patients were
selected and divided into 2 groups, according to the 2 extraction criteria. Group 1, treated with 2 maxillary
premolar extractions, consisted of 49 patients (30 male, 19 female) with a mean age of 14.35 years. Group
2, treated with 4 premolar extractions, consisted of 48 patients (27 male, 21 female) with a mean age of 13.03
years. Treatment times of the groups were compared with the t test. Results: Treatment times were
significantly shorter with the 2-premolar-extraction protocol compared with the 4-premolar-extraction
protocol. Conclusions: Treatment time will be shorter and the occlusal results more predictable with a
2-premolar-extraction protocol compared with 4 premolar extractions. (Am J Orthod Dentofacial Orthop
2006;129:666-71)

C
lass II malocclusions can require different
types of treatment when severity of the antero-
posterior discrepancy, age, and patient compli-
ance are considered.1 Options for correction of Class II
malocclusion include headgear, fixed and removable
functional appliances, fixed appliances with Class II
elastics, extractions, and orthognathic surgery.2-5 Ex-
tractions can involve 2 maxillary premolars,6 or 2
maxillary and 2 mandibular premolars.7 It has been
demonstrated that a 2-maxillary-premolar-extraction
protocol provides a better occlusal success rate than the
4-premolar-extraction protocol.8
The number of teeth extracted and the severity of
the malocclusion can influence treatment time.9 Be-
cause malocclusion severity is an inherent characteris-
tic that cannot be controlled, efforts have been made to
quantify the influence of extractions on the duration of
orthodontic treatment.10,11 Investigations comparing
treatment times between malocclusions treated with
and without extractions demonstrated that the number
From the Department of Orthodontics, Bauru Dental School, University of São
Paulo, Bauru, São Paulo, Brazil.
a
Associate professor.
b
Graduate student.
c
Professor.
Based on research by Dr Fábio Rogério Torres Maria in partial fulfillment of
the requirements for the degree of Master of Science in Orthodontics at Bauru
Dental School, University of São Paulo.
Reprint requests to: Dr 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, July 2004; revised and accepted, September 2004.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.12.026
666
of teeth removed is positively correlated to treatment
time.10-15 In spite of this evidence, Class II treatment
times of 2-maxillary-premolar-extraction and 4 premo-
lar-extraction protocols have not been compared.
Therefore, our objective was to test the following null
hypothesis: complete Class II treatment time is similar
in the 2-maxillary and 4-premolar-extraction protocols.
MATERIAL AND METHODS
The sample was retrospectively selected from the
files of over 2000 treated patients at the Orthodontic
Department at Bauru Dental School, University of São
Paulo, Brazil. Records and the initial dental study
models of all patients who initially had complete
bilateral Angle Class II malocclusions (molar relation-
ship) and were treated with 2 maxillary premolar
extractions or 2 maxillary and 2 mandibular premolar
extractions, and standard fixed edgewise appliances
were selected and divided into 2 groups. Sample
selection was based exclusively on the initial antero-
posterior dental relationship, regardless of any other
dentoalveolar or skeletal characteristic. Additionally,
patients had all permanent teeth up to the first molars,
with no tooth agenesis or supernumerary teeth.
Group 1 consisted of 49 patients treated with 2 first
maxillary premolar extractions (30 male, 19 female) at
an initial mean age of 14.35 years (range, 9.42-27.08
years). Forty-three had Class II Division 1 malocclu-
sions, and 6 had Class II Division 2 malocclusions.
Their treatment plans included the extraction of 2
maxillary premolars. Patients with nonextraction treat-
ment plans were excluded.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 129, Number 5
Group 2 consisted of 48 patients with Class II
Division 1 malocclusions, treated with 4 premolar
extractions (27 male, 21 female) at an initial mean age
of 13.03 years (range, 10.67-18.33 years). Thirty-five
were treated with 4 first premolar extractions, 11 were
treated with first maxillary premolars and second man-
dibular premolar extractions, 1 was treated with 4
second premolar extractions, and 1 was treated with
first and second maxillary premolar extractions on the
left and right quadrants, respectively, and first mandib-
ular premolar extractions.
The mechanics used with the standard fixed edge-
wise appliances included 0.022 x 0.028-in conventional
brackets (not preadjusted), associated with extraoral
headgear and lip bumpers to reinforce anchorage for the
maxillary and mandibular teeth, respectively, when
necessary. Class II elastics were also used when appli-
cable, especially in the 4 premolar-extraction protocol,
to aid in correcting the Class II anteroposterior rela-
tionship. There was no anchorage preparation. The
usual wire sequence began with a 0.015-in twist-flex or
0.016-in nitinol wire, followed by 0.016, 0.018,
0.020-in and, finally, 0.021 ⫻ 0.025-in or 0.018 ⫻
0.025-in stainless steel wires (Unitek, Monrovia, Calif).
In extraction treatment, the canines are initially re-
tracted a small amount to allow space for leveling and
aligning of the anterior teeth. The anterior teeth were
retracted en masse with the rectangular wire, after
leveling and aligning. If a 0.021 ⫻ 0.025-in wire was
being used, the dimensions of the rectangular wire were
electrolytically reduced in the posterior segments to
reduce the friction forces with the brackets and tubes.
The canines and anterior teeth were retracted with
elastic chains. Deep overbites were usually corrected
by reversing and accentuating the curve of Spee of the
stainless steel archwires until obtaining overcorrection.
This overcorrection was maintained by accentuating
and reversing the curve of Spee in the rectangular wire
as well. Fixed or removable functional appliances were
not used.
From the patient records, the following information
was obtained: initial age, sex, date of treatment onset,
date of treatment completion, and total treatment time.
To evaluate the initial malocclusion severity compati-
bility of the groups, the initial treatment priority index
(TPI)16 and the amount of mandibular crowding were
blindly calculated on the pretreatment dental study
models of each patient. The TPI index provides
weighted subscores for overjet, vertical overbite or
open bite, tooth displacement, and posterior crossbite,
as well as summary scores reflecting the overall sever-
ity of malocclusion. With the exception of rotation and
displacement, all TPI components were measured along
Janson et al 667
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
was added to the TPI score. Total scores on the TPI
ranged from 0 to 10 or more, with higher scores
representing more severe malocclusions.17,18
TPI components were defined as follows.17,18
● Overjet: anterior distance from the most 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.
● Overbite or open bite: with the dental models in
centric (convenience) occlusion, the amount of ver-
tical overlap of the maxillary central incisor over the
mandibular central incisor taken as a ratio of the total
crown height (cervix to incisal edge) of the mandib-
ular incisor.
● Tooth displacement: the sum of the number of teeth
noticeably rotated or displaced from ideal alignment,
plus 2 times the number of teeth rotated more than
45° or displaced more than 2 mm.
● First-molar relationship: a constant comprising the
severity of the malocclusion, based on the relation-
ship between the maxillary and mandibular first
molars.
● Posterior crossbite: buccolingual deviation in occlu-
sion of postcanine teeth. The measurement is positive
for buccal crossbite (first molar positioned too far to
the buccal side) or negative for lingual crossbite.
Crossbite is also scored as the number of teeth
deviating from ideal cusp-to-fossa fit by cusp-to-cusp
relation or worse.17,18
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.
Negative values indicated crowding.
Error study
Twenty pairs of dental study models were randomly
remeasured by the same examiner (F.R.T.M.), for the
TPI and the mandibular-crowding evaluations. The
casual error was calculated according to Dahlberg’s
formula19 S2 ⫽ ⌺d2/2n, where S2 is the error variance
and d is the difference between the 2 determinations of
the same variable, and the systematic error with depen-
dent t test,20 for P ⬍.05.
668 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
May 2006

Table I. Results of error study Table II. Results of t test between groups
First Second Group 1 Group 2
measurement measurement (n ⫽ 49) (n ⫽ 48)

Variable Mean SD Mean SD P Dahlberg Variable Mean SD Mean SD t P

TPI 8.37 1.17 8.35 1.08 .804 0.245 Initial TPI 7.94 1.29 8.21 1.09 ⫺.11 .268
Initial MC 2.55 3.04 2.45 2.71 .587 0.591 Initial MC 0.75 1.28 3.44 2.73 ⫺6.22 .000*
Initial age (y) 14.35 2.79 13.03 1.68 2.79 .006*
MC, Mandibular crowding (mm). TT 23.52 5.86 28.12 7.59 ⫺3.35 .001*

*Statistically significant P ⬍.05.

Statistical analyses MC, Mandibular crowding (mm); TT, treatment time (months).
Means and standard deviations for each variable
were calculated to enable characterization of both Table III. Results of t test between subgroups without
groups. T tests were used to compare initial age, TPI, crowding
mandibular crowding, and the treatment times of the
groups. Because mandibular anterior crowding can influ- Subgroup 1 Subgroup 2
(n ⫽ 35) (n ⫽ 14)
ence extraction decisions in the mandibular arch21-24 and
treatment times,25-27 the groups were divided into sub- Variable Mean SD Mean SD t P
groups without crowding. Therefore, these subgroups
Age (y) 14.10 2.26 13.23 1.83 1.28 .204
were similarly compared to eliminate the influence of Initial TPI 7.94 1.35 7.78 0.82 0.40 .687
crowding in the treatment-time results. Results were TT 24.35 5.64 30.13 8.89 ⫺2.72 .008*
considered significant at P ⬍.05.
*Statistically significant P ⬍.05.
TT, Treatment time (months).
RESULTS
There were no systematic errors in the TPI and initial
mandibular crowding evaluation (Table I). The casual dency for a 4-premolar-extraction protocol. For that
errors were within acceptable levels. The groups were reason, the groups were divided into subgroups without
compatible regarding initial TPI, but the subjects in crowding; they were compared with the t test to
group 2 had more crowding and younger initial ages investigate any interference of this initial difference in
than those in group 1. Treatment times were also longer the results. The 6 Class II Division 2 subjects in group
in group 2 (Table II). When the groups were divided 1 and none in group 2 should not cause incompatibility
into noncrowded subgroups, their initial age and TPI of the groups, because the larger score of the TPI from
were compatible, but treatment time in subgroup 2 was a larger overjet in the Division 1 subjects would be
longer than in subgroup 1 (Table III). compensated by the larger overbite of the Division 2
subjects. Accordingly, the anchorage reinforcement
DISCUSSION would also be similar because of the greater labial
The subjects were selected on the basis of having crown torque that should be applied to the maxillary
complete bilateral Class II malocclusions, indepen- incisors to correct their inclination and to retract them
dently of cephalometric skeletal characteristics. Be- in the Class II Division 2 subjects.
cause both groups were similarly chosen, it could be Group 1 had a significantly shorter treatment time
expected that these characteristics would be evenly than group 2 (Table II). This result corroborates the
distributed among them. Usually, it is not the skeletal findings of several studies in which shorter treatment
characteristics of a Class II malocclusion that primarily times were related to protocols with fewer extrac-
determine whether it should be treated with 2 or 4 tions.10,11,13-15,28,29 Group 1 patients had a significantly
premolar extractions but, rather, the dentoalveolar char- higher age range than group 2; this tends to make Class
acteristics. II treatment more difficult and consequently longer, as
Regarding the initial compatibility of the 2 groups, found in previous studies.30,31 However, the results
Table II shows no statistically significant differences in suggested otherwise, and this age difference even
initial TPI between groups. However, the statistically corroborated them. Comparing the subgroups without
significant difference between the initial crowding of initial crowding demonstrated a similar tendency
both groups might influence the decision between the (Table III). Treatment time in the noncrowded subgroup
treatment protocols and perhaps treatment time. The 2 tended to be slightly greater than that in group 2 (Tables
greater the mandibular crowding, the greater the ten- II and III). This tendency opposes previous speculations
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 129, Number 5
that crowding increases treatment time.25-27 Generally, it
might be reasonable to expect that crowding would
increase treatment time because it increases the severity of
the malocclusion, which is more difficult to treat.11,32-34
However, this might not apply in every situation,
especially when complete Class II malocclusion treat-
ment protocols are being compared, such as in this
study. It could be speculated that there was a tendency
for treatment time to be shorter in group 2 than in the
noncrowded subgroup 2 because, after the mandibular
extractions in the crowded subjects, most of the spaces
are used to correct crowding during the leveling and
alignment phase, leaving minor spaces to be closed
during the anterior en-masse retraction phase. On the
other hand, in noncrowded subjects, in whom mandib-
ular extractions were performed to correct incisor
proclination, only small amounts of the spaces are
closed during leveling and alignment, and most of the
spaces are closed during the retraction phase. This
would increase retraction time and overall treatment
time. Further specific studies are necessary to confirm
this speculation.
According to Fink and Smith,10 each premolar
extraction accounts for an additional 0.9 months of
treatment. Our study demonstrated that treatment
time in the 4-premolar-extraction group was longer
than the treatment time in the 2-maxillary-premolar
protocol than would be expected, based on the study
of Fink and Smith (Tables II and III). This suggests
that other variables might influence treatment time in
this comparison. It is speculated that this variable is
the anteroposterior molar Class II relationship cor-
rection that is necessary in group 2. Patients must
comply in using extraoral headgear or Class II
elastics to correct Class II anteroposterior discrepan-
cies.8,35-38 If the necessary compliance level is not
obtained, the occlusal results are compromised,35,39
and treatment time will be increased.32 Previous
studies that compared treatment times in extraction
and nonextraction subjects did not distinguish be-
tween Class I and Class II malocclusions and did not
compare 2- and 4-premolar-extraction protocols in
complete Class II malocclusion corrections.10,11,13-
15,28,29 According to this rationale, it would be
expected that a Class II malocclusion treated with 2
premolar extractions could have a treatment time
similar to that of 4-premolar extraction Class I
treatment.40,41 The required time to close the maxil-
lary extraction spaces in Class II patients would be
similar to the time necessary to simultaneously close
the maxillary and mandibular spaces in Class I
patients. However, if 4 premolars are extracted in
Class II malocclusions, treatment time is increased
Janson et al 669
not because of the greater amount of space to be
closed, but because of the Class II anteroposterior
relationship that must be corrected9; this depends on
patient compliance in using headgear or Class II
elastics.8,35,38,40
Group 2 and subgroup 2 had treatment times that
were 4.6 and 5.78 months longer than group 1 and
subgroup 1, respectively. This might not be consid-
ered clinically significant, but, when patients or
parents are very demanding, it might represent a
doctor/patient/parents relationship problem. To be
efficient, one must consider every aspect that can
influence treatment time. The treatment protocol is
only 1 aspect. If other variables that also cause minor
treatment time increases act simultaneously, the
overall increase could be clinically significant. Ad-
ditionally, the patients were not selected based on
excellent treatment outcomes. It has been suggest-
ed37,40 and demonstrated8 that in Class II patients the
4-premolar-extraction protocol has more compli-
cated orthodontic mechanics, and therefore its occlu-
sal success rate is lower than the 2-premolar-extrac-
tion protocol, especially in complete Class II
malocclusions. The most difficult aspect to be cor-
rected in the 4-premolar-extraction protocol is the
Class II anteroposterior discrepancy. Therefore, be-
cause correction of anteroposterior discrepancies in
complete Class II 4-premolar-extraction protocols
requires more patient compliance, presumably treat-
ment time in well-finished patients would be even
longer, when compared with well-finished patients
with 2-maxillary-premolar extractions; this should
be investigated in the future.
Treatment times for both groups in this study were
longer than reported in the literature.13,28,42 Perhaps
this can be explained because graduate students treated
them, whereas in the other investigations the patients
were treated in private practices. It is speculated that
treatment times are usually shorter in the hands of more
experienced clinicians.32,43
Clinical implications
Considering that the 4-premolar-extraction pro-
tocol for Class II malocclusion treatment usually has
longer treatment times and less satisfactory occlusal
success rates,8 because greater compliance is needed
for the treatment mechanics than the 2-premolar-
extraction protocol, it should be used in carefully
selected patients. The decision in every treatment
plan depends on a cost-benefit ratio.44 The orthodon-
tic treatment goals usually include obtaining good
facial balance, an optimal static and functional oc-
clusion, and stable treatment results.12,45 Four pre-
670 Janson et al
molar extractions in complete Class II patients are
usually used to correct crowding and incisor procli-
nation, leading to these objectives. Nevertheless,
because of the great orthodontic discrepancies and
the patients’ primary concerns, optimal objectives
cannot always be attained.12 Therefore, when con-
sidering the several variables involved, one must also
consider the greater difficulty and time in obtaining a
good occlusal result in complete Class II malocclu-
sion treatment with the 4premolar-extraction proto-
col. For example, it may be that to provide an
optimal facial balance, a 4-premolar-extraction pro-
tocol in a complete Class II malocclusion would be
the best option. However, because of the patient’s
advanced age and poor compliance attitude, along
with increased treatment time, a 2-premolar-extrac-
tion protocol would provide greater benefits and
would be the selected treatment option. If the bene-
fits of a 4-premolar-extraction protocol in Class II
malocclusion treatment outweigh the time and the
greater mechanical difficulty costs,8 it should be
undertaken. Otherwise, a 2-premolar-extraction pro-
tocol should be preferred. The treatment objectives
might be compromised, but treatment time will be
shorter, and the occlusal results more predictable.
CONCLUSIONS
The null hypothesis was rejected because complete
Class II treatment time with the 2-premolar-extraction
protocol was significantly shorter than treatment time
with the 4-premolar-extraction protocol.
REFERENCES
1. Salzmann JA. Practice of orthodontics. Philadelphia: J. B.
Lippincott; 1966.
2. Aelbers CMF, Dermaut LR. Orthopedics in orthodontics: part I,
fiction or reality—a review of the literature. Am J Orthod
Dentofacial Orthop 1996;110:513-9.
3. Bishara SE, Cummins DM, Zaher AR. Treatment and posttreat-
ment changes in patients with Class II, Division 1 malocclusion
after extraction and nonextraction treatment. Am J Orthod
Dentofacial Orthop 1997;111:18-27.
4. Edwards JG. Orthopedic effects with “conventional” fixed orth-
odontic appliances. Am J Orthod 1983;84:275-91.
5. Proffit WR, Phillips C, Tulloch JFC, Medland PH. Surgical
versus orthodontic correction of skeletal Class II malocclusion in
adolescents: effects and indications. Int J Adult Orthod Orthog-
nath Surg 1992;7:209-20.
6. Cleall JF, Begole EA. Diagnosis and treatment of Class II
Division 2 malocclusion. Angle Orthod 1982;52:38-60.
7. Strang RHW. A textbook of orthodontics. Philadelphia: Lea &
Febiger; 1950.
8. Janson G, Brambilla AC, Henriques JFC, Freitas MR, Neves LS.
Class II treatment success rate in 2- and 4-premolar extraction
protocols. Am J Orthod Dentofacial Orthop 2004;125:472-9.
American Journal of Orthodontics and Dentofacial Orthopedics
May 2006
9. Vig KWL, Weyant R, Vayda D, O’Brien KD, Bennett E.
Orthodontic process and outcome: efficacy studies—strategies
for developing process and outcome measures: a new era in
orthodontics. Clin Orthod Res 1998;1:147-55.
10. Fink DF, Smith RJ. The duration of orthodontic treatment. Am J
Orthod Dentofacial Orthop 1992;102:45-51.
11. O’Brien KD, Robbins R, Vig KWL, Vig PS, Shnorhokian H,
Weyant R. The effectiveness of Class II, Division 1 treatment.
Am J Orthod Dentofacial Orthop 1995;107:329-34.
12. Alexander RG, Sinclair PM, Goates LJ. Differential diagnosis
and treatment planning for the adult nonsurgical patient. Am J
Orthod 1986;89:95-112.
13. Alger DW. Appointment frequency versus treatment time. Am J
Orthod Dentofacial Orthop 1988;94:436-39.
14. De Saturno LD. La duracion del tratamiento ortodoncico y sus
condicionantes [thesis]. Caracas: Universidad de Caracas; 1994.
p. 100.
15. Vig PS, Weintraub JA, Brown C, Kowalski CJ. The duration of
orthodontic treatment with and without extractions: a pilot study
of five selected practices. Am J Orthod Dentofacial Orthop
1990;97:45-51.
16. Grainger RM. Orthodontic treatment priority index. PHS publi-
cation number 1000-Series 2, number 25. Washington: US
Government Printing Office; 1967.
17. Corruccini R, Potter R. Genetic analysis of occlusal variation in
twins. Am J Orthod 1980;78:140-54.
18. Corruccini R, Whitley L. Occlusal variation in a rural Kentucky
community. Am J Orthod 1981;79:250-62.
19. Dahlberg G. Statistical methods for medical and biological
students. New York: Interscience; 1940.
20. Houston WJB. Analysis of errors in orthodontic measurements.
Am J Orthod 1983;83:382-90.
21. Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to
extract: part II. Analysis of clinicians’ stated reasons for extrac-
tion. Am J Orthod Dentofacial Orthop 1996;109:393-402.
22. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial
and soft tissue changes in Class II, Division 1 cases treated with
and without extractions. Am J Orthod Dentofacial Orthop 1995;
107:28-37.
23. DeAngelis V. Selection of teeth for extraction as an adjunct to
orthodontic treatment. J Am Dent Assoc 1973;87:610-5.
24. Wertz RA. Diagnosis and treatment planning of unilateral Class
II malocclusions. Angle Orthod 1975;45:85-94.
25. Lewis PD. Canine retraction. Am J Orthod 1970;57:543-60.
26. Liou EJ, Huang CS. Rapid canine retraction through distraction
of the periodontal ligament. Am J Orthod Dentofacial Orthop
1998;114:372-82.
27. Maggioncalda EA. Treatment of a Class II, Division 1 vertical
growth pattern with severe anterior crowding. Am J Orthod
Dentofacial Orthop 1997;112:300-8.
28. Amditis C, Smith LF. The duration of fixed orthodontic treat-
ment: a comparison of two groups of patients treated using
edgewise brackets with 0.018⬙ and 0.022⬙ slots. Aust Orthod J
2000;16:34-9.
29. Richmond S, Andrews M, Roberts CT. The provision of orth-
odontic care in the general dental service of England and Wales:
extraction patterns, treatment duration, appliance types and
standards. Br J Orthod 1993;20:345-50.
30. Harris EF, Dyer GS, Vaden JL. Age effects on orthodontic
treatment: skeletodental assessments from the Johnston analysis.
Am J Orthod Dentofacial Orthop 1991;100:531-6.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 129, Number 5
31. Tulloch JF, Proffit WR, Phillips C. Influences on the outcome of
early treatment for Class II malocclusion. Am J Orthod Dento-
facial Orthop 1997;111:533-42.
32. Chew MT, Sandham A. Effectiveness and duration of two-arch
fixed appliance treatment. Aust Orthod J 2000;16:98-103.
33. Holman JK, Hans MG, Nelson S, Powers MP. An assessment of
extraction versus nonextraction orthodontic treatment using the
peer assessment rating (PAR) index. Angle Orthod 1998;68:
527-34.
34. Turbill EA, Richmond S, Wright JL. The time-factor in orth-
odontics: what influences the duration of treatments in National
Health Service practices? Community Dent Oral Epidemiol
2001;29:62-72.
35. Anderson BD. Multiple extraction patterns in severe discrepancy
cases. Angle Orthod 1975;45:291-303.
36. Vaught RA. Treatment of a Class II Division 1 malocclusion
with a high mandibular angle. Am J Orthod Dentofacial Orthop
2000;118:229-33.
37. Bryk C, White LW. The geometry of Class II correction with
extractions. J Clin Orthod 2001;35:570-9.
38. Runge ME, Sadowsky C. Class II, Division 1 vertical pattern.
Am J Orthod Dentofacial Orthop 1988;94:271-7.
Janson et al 671
39. Janson G, Janson MR, Cruz KS, Henriques JFC, Freitas MR.
Unusual orthodontic retreatment. Am J Orthod Dentofacial
Orthop 2003;123:468-75.
40. Andrews LF. The straight wire appliance. Syllabus of philosophy
and techniques. 2nd ed. San Diego: Larry F. Andrews Founda-
tion of Orthodontic Education and Research. 1975.
41. Kremenak CR, Kinser DD, Harman HA, Menard CC, Jakobsen
JR. Orthodontic risk factors for temporomandibular disorders
(TMD). I: premolar extractions. Am J Orthod Dentofacial Orthop
1992;100:13-20.
42. Vaden JL, Kiser HE. Straight talk about extraction and nonex-
traction: a differential diagnostic decision. Am J Orthod Dento-
facial Orthop 1996;109:445-52.
43. McGuinness NJ, McDonald JP. The influence of operator
changes on orthodontic treatment times and results in a postgrad-
uate teaching environment. Eur J Orthod 1998;20:159-67.
44. Shaw WC, O’Brien KD, Richmond S, Brook P. Quality control
in orthodontics: risk/benefit considerations. Br Dent J 1991;170:
33-7.
45. Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-tissue
profile changes: a study of three analyses. Am J Orthod 1985;
88:209-23.