ORIGINAL ARTICLE

Treatment stability in patients with Class II

malocclusion treated with 2 maxillary
premolar extractions or without extractions
Guilherme Janson,a Leonardo Tavares Camardella,b Janine Della Valle Araki,b
Marcos Roberto de Freitas,c and Arnaldo Pinzand
Bauru, Brazil

Introduction: The purpose of this study was to compare the occlusal stability of Class II malocclusion treat-
ment with and without extraction of 2 maxillary premolars. Methods: A sample of 59 records from patients with
complete Class II malocclusion was used. This sample was divided into 2 groups with the following charac-
teristics: group 1, comprising 29 patients treated without extractions, and group 2, comprising 30 patients
treated with extraction of 2 maxillary premolars. Dental cast measurements were obtained before and after
treatment and at a minimum of 2.4 years after treatment. The pretreatment, posttreatment, and postretention
occlusal statuses were evaluated with the peer assesment rating index. The occlusal indexes at the postreten-
tion stage and the posttreatment changes and percentages of posttreatment changes were compared with t
tests. Results: The nonextraction and the 2 maxillary premolar extraction treatment protocols of complete
Class II malocclusions had no statistically significant differences in occlusal stability. Conclusions: Finishing
Class II malocclusion treatment with the molars in a Class II relationship has similar occlusal stability as finish-
ing with the molars in a Class I relationship. (Am J Orthod Dentofacial Orthop 2010;138:16-22)

I
nitially, it was thought that the molars should
always finish in a Class I relationship.1-4 It was
also suspected that finishing with the molars in
a Class II relationship could cause temporomandibular
joint problems5,6 and that stability could be
compromised.7,8 Later, many orthodontists realized,
and researchers proved, that, in some Class II
malocclusions, the molars could be finished in
a Class II relationship without unfavorable collateral
effects.9-14 Enough clinical and scientific evidence
has been provided to support finishing treatment of
certain Class II malocclusions with the molars in
a Class II relationship. Indirect evidence also suggests
that stability is not compromised when finishing with
the molars in a Class II relationship.15-18
From the Department of Orthodontics, Bauru Dental School, University of São
Paulo, Bauru, São Paulo, Brazil.
a
Professor and Head.
b
Graduate student.
c
Professor.
d
Associate professor.
Based on research by the second author in partial fulfillment of the requirements
for the degree of master of science in orthodontics.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
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, May 2008; revised and accepted, August 2008.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.08.033
16
It has been shown that the 2 maxillary premolar ex-
traction protocol has greater efficiency than the nonex-
traction treatment of Class II malocclusions.19 In
addition to efficiency, long-term stability is a primary
goal in orthodontics; this is difficult to obtain.20,21
Studies have shown that, even though improvement can
be obtained through orthodontic treatment, there is
a tendency of relapse to the original malocclusion
many years after appliance removal.21-24 Consequently,
every effort should be directed to minimize the risks
that can compromise the results of orthodontic treatment.
Studies comparing the stability of Class II malocclu-
sion treatment with 4 premolar extractions and nonex-
traction found no significant differences between these
protocols.21,23,25-28 However, similar studies
comparing the long-term stability of the 2 maxillary
premolar extraction protocol with the nonextraction
approach have not been performed.18 Therefore, to
further clarify these issues, we compared the long-
term stability of Class II malocclusions treated with
and without extraction of 2 maxillary premolars.
MATERIAL AND METHODS
The sample was retrospectively selected from the
files of the orthodontic department at Bauru Dental
School, University of São Paulo, in Brazil; the files in-
clude over 4000 documented patients. The records and
the initial (T1), final (T2) and long-term posttreatment
American Journal of Orthodontics and Dentofacial Orthopedics Janson et al 17
Volume 138, Number 1

Table I. Compatibility of groups concerning the distri- Table II. Intergroup comparison of the studied variables
bution of malocclusion types and sex (chi-square test) (t test)
Class II Class II Group 2
Division 1 (n) Division 2 (n) Total (n) (2 maxillary
Group 1 premolar
Group 1 24 5 29 (nonextraction), extractions),
Group 2 22 8 30 n 5 29 n 5 30
Total 46 13 59
Variable Mean SD Mean SD P
Male (n) Female (n) Total (n)
PAR 1 23.5 6.89 23.70 6.78 0.918
Group 1 14 15 29 PAR 2 3.55 3.50 2.03 2.59 0.062
Group 2 17 13 30 Treatment time (y) 2.51 0.98 2.24 0.75 0.237
Total 31 28 59 Posttreatment time (y) 7.26 3.43 9.60 3.55 0.012*
Age 1 (y) 12.65 1.38 13.32 1.52 0.081
Chi-square 5 0.42; df 5 1; P 5 0.518. Age 2 (y) 15.17 1.58 15.57 1.71 0.357
Chi-square 5 0.76; df 5 1; P 5 0.382. Age 3 (y) 22.44 3.50 25.18 3.97 0.006*
PAR 3 4.41 3.71 5.13 5.53 0.561
PAR posttreatment 0.86 3.49 3.10 5.24 0.059
(T3) (at least 2.3 years) dental study models of all pa- changes
PAR posttreatment 3.60 15.80 15.13 32.33 0.088
tients who initially had complete bilateral Class II mal-
changes (%)
occlusion (molar relationship) and were treated without
extractions or with 2 maxillary premolar extractions *Statistically significant at P \0.05.
and standard fixed edgewise appliances were selected
and divided into 2 groups.29-31 Sample selection was
based exclusively on the initial anteroposterior dental 0.016-, 0.018-, 0.020-, and 0.021 3 0.025- or 0.018 3
relationship, regardless of any other dentoalveolar or 0.025-in stainless steel wires (all from 3M Unitek, Mon-
skeletal characteristic. Additionally, patients had all rovia, Calif). Deepbites were corrected with accentu-
permanent teeth up to the first molars and no dental ated and reversed curve of Spee. In group 2, the
anomalies of number, size, and form. Group 1 anterior teeth were retracted en masse with a rectangular
consisted of 29 patients (14 boys, 15 girls) treated wire and elastic chains for overjet and Class II canine
without extractions at an initial mean age (age 1) of correction. Extraoral headgear was used to correct the
12.65 6 1.38 years (range, 9.52-15.90 years); 22 had Class II anteroposterior relationship in group 1; in group
Class II Division 1 malocclusion, and 5 had Class II 2, an extraoral appliance was indicated to reinforce an-
Division 2 malocclusion. The posttreatment age (age chorage and maintain the Class II molar relationship.
2) of the patients was 15.17 6 1.58 years (range, Twelve patients in group 1 used functional appliances
12.94-18.72 years), and the postretention age (age 3) either alone or with extraoral headgear. When neces-
was 22.44 6 3.50 years (range, 16.29-31.76 years). sary, Class II elastics were used in group 1 to help obtain
The average treatment time was 2.51 6 0.98 years a Class I molar relationship; in group 2, this procedure
(range, 0.88-4.70 years), and the average was used to help maintain a Class II molar relationship.
postretention time was 7.26 6 3.43 years (range, A Hawley plate was used for retention during a mean
2.40-16.15 years). Group 2 consisted of 30 patients period of 1 year, and a mandibular canine-to-canine
(17 boys, 13 girls) treated with 2 maxillary premolar fixed retainer was recommended to be used for
extractions; at age 1, they were 13.32 6 1.52 years a mean period of 3 years. However, at the postretention
(range, 11.21-17.09 years); 22 had Class II Division 1 stage, 15 patients in group 1 and 13 in group 2 still had
malocclusion, and 8 had Class II Division 2 their mandibular fixed retainers.
malocclusion. At age 2, they were 15.57 6 1.71 years The peer assessment rating (PAR) index32 was cal-
(range, 12.55-19.48 years). and, at age 3, they were culated on the pretreatment, posttreatment, and postre-
25.18 6 3.97 years (range, 19.02-34.04 years). The tention study models of each patient, according to the
average treatment time was 2.24 6 0.75 years (range, American weightings suggested by De Guzman et al33
0.93-4.19 years), and the average postretention time by 1 examiner (L.T.C.). Initial, final, and postretention
was 9.60 6 3.55 years (range, 3.23-15.99 years). occlusal characteristics were ranked by scores for molar
Orthodontic mechanics included fixed edgewise ap- and premolar anteroposterior (AP) relationship, overjet
pliances, with 0.022 X 0.028-in conventional brackets (OJ), overbite (OB), midline, crossbite, and crowding to
and a usual wire sequence characterized by an initial quantify the initial malocclusion severity (PAR 1), the
0.015-in Twist-Flex or 0.016-in Nitinol, followed by treatment occlusal results (PAR 2), the percentage of
18 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2010

Table III. Comparison of the studied variables in the sub- Intergroup comparisons of the individual PAR
Table IV.
groups with compatible posttreatment time and age at components at T2 and T3 and the posttreatment changes
T3 (t test) (Mann-Whitney U test)
Subgroup 2 Group 2
(2 maxillary (2 maxillary
Subgroup 1 premolar Group 1 premolar
(nonextraction), extractions), (non-extraction), extractions),
n 5 28 n 5 26 n 5 29 n 5 30

Variable Mean SD Mean SD P Variable Mean rank P

Treatment time (y) 2.51 1.00 2.26 0.63 0.269 Posterior segments 31.50 28.55 0.509
Posttreatment time (y) 7.31 3.48 8.89 3.16 0.087 AP discrepancy at T2
Age 1 (y) 12.64 1.40 13.05 1.35 0.276 Posterior segments 33.72 26.40 0.101
Age 2 (y) 15.16 1.61 15.31 1.48 0.713 AP discrepancy at T3
Age 3 (y) 22.47 3.56 24.21 3.27 0.068 Posttreatment change 32.60 27.48 0.252
PAR 3 4.46 3.77 5.07 5.89 0.648 in posterior segments
PAR posttreatment changes 1.14 3.20 3.19 5.60 0.102 AP discrepancy (T3-T2)
PAR posttreatment 4.35 15.55 16.06 34.60 0.110 OJ at T2 30.53 29.48 0.814
changes (%) OJ at T3 28.50 31.45 0.509
Posttreatment change in OJ 28.10 31.83 0.404
T3, long-term posttreatment. (T3-T2)
OB at T2 31.09 28.95 0.632
OB at T3 30.28 29.73 0.903
Posttreatment change in OB 29.90 30.10 0.963
PAR treatment changes, and the percentage of PAR
(T3-T2)
posttreatment changes,34-36 which are better estimates Crowding at T2 29.50 30.48 0.825
of the occlusal changes.37 Crowding at T3 28.47 31.48 0.499
Twenty-five maxillary and mandibular final dental Posttreatment change 28.93 31.03 0.638
models were randomly selected and remeasured by in crowding (T3-T2)
the same examiner. Student paired t tests were used to T2, final; T3, long-term posttreatment.
evaluate the systematic error at P\0.05.38 Casual errors
were P calculated according to Dahlberg’s formula,39
Se 5 d2 =2n, where d is the difference between du-
2 To investigate whether the posttreatment changes
plicate measurements and n is the number of double were associated with the treatment changes, the Pearson
measurements. correlation test was used. The Spearman correlation test
was used to evaluate whether the posttreatment changes
Statistical analysis of OJ and OB were associated with the treatment
changes.
Compatibility of the groups concerning the distribu- With the objective of assessing the influence of
tions of Class II malocclusion types and sex was evalu- treatment time in Class II treatment stability, the sample
ated with chi-square tests. The t test was used to was divided into 2 groups, independent of the treatment
evaluate compatibility at PAR 1 and PAR 2, and at protocol, and compared with t tests. One group had
age 1, age 2, and age 3. It was also used to compare treatment times less than 2 years, and the other, more
the groups at PAR 3 for the amounts and percentages than 3 years. The results were considered statistically
of posttreatment changes. significant at P \0.05.
The occlusal results obtained for each component of
the PAR index at T2 and T3, and the posttreatment
changes were individually compared between the RESULTS
groups with the Mann-Whitney U test. A nonparametric There was no statistically significant systematic er-
test was used because the values of each PAR compo- ror, and the random error was 0.98 for the PAR index.
nent did not have normal distribution, according to the The groups were compatible regarding malocclu-
Kolmogorov-Smirnov test. sion type and sex distribution, PAR 1, PAR 2, treatment
Because the 2 groups had patients with and without time, age 1, and age 2. However, group 2 had greater
mandibular fixed canine-to-canine retention, t tests values for posttreatment time and age 3 (Tables I and II).
were used to compare the stability of the patients in There were no intergroup differences regarding PAR
each group to determine whether the fixed retention 3, the posttreatment occlusal changes, and the percent-
influenced the stability. age of posttreatment occlusal changes (Table II).
American Journal of Orthodontics and Dentofacial Orthopedics Janson et al 19
Volume 138, Number 1

Table V. Comparisons of stability between subjects with Table VI. Pearson correlation coefficients between treat-
and without fixed mandibular canine-to-canine reten- ment and posttreatment changes
tion in groups 1 and 2 at T3 (t test) PAR Percent PAR
Without With posttreatment posttreatment
canine-to-canine canine-to-canine Variable changes changes
retainer, n 5 14 retainer, n 5 15
PAR treatment changes r 5 0.092
Variable Mean SD Mean SD P P 5 0.488
Percent PAR treatment r 5 0.156
Group 1 changes P 5 0.237
PAR 2 3.71 3.53 3.40 3.58 0.814
PAR 3 4.78 4.50 4.06 2.91 0.611
PAR index 1.07 3.19 0.66 3.84 0.761
posttreatment changes Class II malocclusion groups treated without extrac-
Percent PAR 5.19 15.93 2.12 16.08 0.609 tions or with extraction of 2 maxillary premolars
posttreatment changes (Table II). This conclusion contradicts the idea that
Group 2 (n = 17) (n = 13)
finishing with a Class II molar relationship could
PAR 2 2.58 3.08 1.30 1.60 0.184
PAR 3 4.82 5.72 5.53 5.47 0.732 compromise treatment stability.7,8 Therefore, this
PAR posttreatment 2.23 5.28 4.23 5.16 0.309 confirms that Class II correction stability does not
changes depend on the treatment protocol, as concluded in
PAR posttreatment 10.43 27.29 21.27 38.22 0.371 comparative stability studies between nonextraction
changes (%)
and 4 premolar extraction protocols of Class II
malocclusions.21,23,25-27
Because group 2 had greater posttreatment time and The occlusal statuses at the postretention stage and the
postretention age, these variables were again compared posttreatment changes in both groups were also
after matching the groups for posttreatment time and satisfactory, with no clinical significance. The mean
postretention age. The differences were also nonsignif- occlusal status was within the acceptable degree for fin-
icant (Table III). ished patients (PAR 5 55 points); the mean relapse
There were no intergroup differences regarding the amount was only 3.1 PAR points in group 2, which is fa-
several individual PAR components at the posttreatment vorable40 (Table II). These results confirm most studies
and postretention stages and their changes between that showed good stability of Class II correction.21,27,41-45
these stages (Table IV). Nevertheless, because the posttreatment times and
No difference was found within groups regarding the postretention ages of the groups were different, it
PAR 3, posttreatment occlusal changes, and percentages could be argued that these factors could have influenced
of posttreatment occlusal changes between patients who the results.26,46,47 After we matched the groups for these
still had a mandibular canine-to-canine fixed retainer factors, the results continued to show no significant
and those without it (Table V). differences (Table III). Also, despite the shorter post-
There were no significant correlations between treatment time and postretention age (which would fa-
treatment and posttreatment occlusal changes (Tables vor this group), group 1 did not have significantly
VI and VII), and also no differences in stability between greater stability than group 2.
patients treated in less than 2 years and those treated in Therefore, it can be concluded that in the long term,
more than 3 years (Table VIII). the time after treatment did not influence the stability
between the 2 groups. This statement confirms what
others have stated: that most relapses occur in the first
DISCUSSION posttreatment years, and the occlusion tends to stabilize
The 59 subjects in this study, from the 4000 patients after that, except for displacement of the mandibular in-
available, might seem too few. This was consequent to cisors’ contact points, which tend to increase over the
the rigid selection criteria applied, especially that the years.46-49
subjects must have complete Class II malocclusion at No PAR component showed a statistically signifi-
pretreatment, and the necessary records were available cant difference between the groups (Table IV). This re-
or could be obtained. Additionally, some patients were sult confirms that the AP arch relationship does not
not included to match the groups regarding these change with time when the orthodontic treatment is fin-
factors. ished in a Class II molar relationship, contradicting
The results showed no statistical significant differ- statements that, with time, the mandibular molars tend
ences in the occlusal stability between complete to move more distally in patients with a Class II molar
20 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2010

Spearman correlation coefficients between

Table VII. ment stability was similar when molars were finished
treatment and posttreatment overjet and overbite in a Class I or a Class II relationship; this was the orig-
changes inal dilemma. Other variables such as patient compli-
Variable n Spearman P
ance might have played a role in deciding between
them. However, these variables would have been un-
OJ treatment changes 59 0.166 0.206 likely to have influenced the results. These results
X OJ posttreatment changes were obtained from a retrospective study because of
OB treatment changes 59 0.093 0.480
X OB posttreatment changes
the evident difficulties in obtaining significantly large
prospective samples with these characteristics. How-
ever, it would be interesting to confirm our results
Table VIII. Comparisons of Class II treatment stability
with prospective studies.
between patients treated in short and long periods of
CONCLUSIONS
time (t test)
\2 years, n 5 27 .3 years, n 5 13 1. There is no difference in the occlusal stability in the
Variable Mean SD Mean SD P treatment of patients with complete Class II maloc-
clusion without extractions or with 2 maxillary pre-
PAR 3 4.88 4.81 5.30 5.73 0.809 molar extractions.
PAR posttreatment 2.07 4.45 2.53 5.25 0.772 2. Therefore, finishing treatment with the molars in
changes
PAR posttreatment 9.34 23.09 15.31 40.60 0.556
a Class I or a Class II relationship provides similar
changes (%) stability in patients with Class II malocclusion.

50
relationship. However, this was found in untreated
subjects with Class II malocclusion.50
Prolonged use of a mandibular canine-to-canine
fixed retainer also did not influence the stability in the
groups; there was no significant difference within
groups of patients with and without the retainer, corrob-
orating a previous study51 (Table V). Nevertheless, this
refers to overall occlusal stability and not specifically to
the stability of mandibular incisor alignment.
Treatment changes were not significantly correlated
to posttreatment changes (Tables VI and VII). These
results contradict those of other studies that concluded
that the greater the treatment changes, the greater the
posttreatment relapse.21,22,52-55 It might be consequent
to the small mean relapse in the investigated groups,
but this still should be more thoroughly investigated.
There is speculation that short treatment time is as-
sociated with greater relapse.56-58 However, when
patients with less than 2 years of treatment were
compared with those with more than 3 years of
treatment, no significant difference was found (Table
VIII). This demonstrates that the orthodontist, in addi-
tion to treating to obtain greater stability, should also
strive to treat patients more efficiently in less time but
without neglecting the necessary active retention time,
especially with Class II malocclusion nonextraction
protocols.19
We were not concerned about evaluating whether
the patients were correctly diagnosed and treated with
these 2 treatment protocols but, rather, whether treat-
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