ORIGINAL ARTICLE

Tooth movement after orthodontic treatment with

4 second premolar extractions
Kun Chen,a Xianglong Han,b Lan Huang,b and Ding Baic
Chengdu, Sichuan, China

Introduction: This retrospective study was designed to investigate the position changes and movement
patterns of incisors and molars after orthodontic treatment with extractions of 4 second premolars in patients
with mild crowding, slight dental protrusion, and Angle Class I relationship. Methods: Pretreatment and post-
treatment cephalograms of 26 subjects were chosen from patients treated by an experienced orthodontist.
The movements of the incisors and the molars as well as tooth tipping were measured. Results: Relative to
the posttreatment occlusal plane, the mean incisor movements were 3.3 and 2.9 mm lingually in the maxilla
and the mandible, respectively. The first molars were moved mesially an average of 3.2 and 3.4 mm in the max-
illa and the mandible, respectively. The incisor inclination was under proper control. The extraction space was
almost equally taken up by the anterior and posterior segments. Conclusions: These data can be used to
estimate the expected position changes and movement patterns of the incisors and molars in patients with
mild crowding and slight bialveolar dental protrusion after orthodontic treatment with 4 second premolar
extractions. (Am J Orthod Dentofacial Orthop 2010;138:770-7)

T
he first premolar has been the most common tooth
removed in orthodontic clinics, as suggested by
previous articles.1,2 But, in some patients with
mild crowding, acceptable incisor positions and facial
profiles, the second premolar would be an alternative to
the first premolar to be extracted.3-5 Nance6 was one of
the first to propose this; underlying his and some other ad-
vocates’ recommendations was the concept that second
premolar removal would result in less incisor retraction
and consequently less lip retraction compared with first
premolar removal.3-6 It is widely accepted that the
anchorage potential is highly related to the area of root
surface involved.7,8 Proffit9 figured out that less incisor re-
traction effect would be anticipated while extracting the
further posteriorly located tooth. And the space of second
premolar extraction was mainly occupied by mesial
movement of the molars, but some retraction of the incisor
could occur. This incisor retraction effect has been
confirmed by other researchers.3,4
From the State Key Laboratory of Oral Disease (Sichuan University), West
China Stomatology Hospital of Sichuan University, Chengdu, Sichuan, China.
a
Postgraduate student; PhD candidate, Discipline of Orthodontics, Faculty of
Dentistry, University of Hong Kong, Hong Kong SAR, China.
b
Postgraduate student.
c
Professor.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Ding Bai, 14 3rd section, Ren Min Nan Lu Rd, Chengdu,
Sichuan, China; e-mail, baiding88@hotmail.com.
Submitted, November 2008; revised and accepted, January 2009.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.01.030
770
Despite the agreement that improvement in orthodon-
tic techniques increases the potential to freely move teeth
3 dimensionally and to correlate these movements with
expected facial growth changes,8 it is still believed
that a particular premolar removal will have predictable
incisor and molar position changes.5,6 Diagnosis and
treatment planning are based on this prediction;
accordingly, the plan is executed to ensure that the teeth
will ultimately reside in the predetermined positions.8
When reviewing studies that examined the effects of
second premolar extraction treatment on tooth move-
ment, we found that most reports were based on clinical
observations; there is little scientific information to
make an accurate prediction of extraction space distri-
bution.8 Also, controversy surrounds the distances of in-
cisor and molar movement. Some authors reported little,
if any, incisor change, and the extraction site was almost
taken up by molars.3,4 But others found that the incisors
were retracted remarkably, even as much as 3 mm.10,11
Underlying this inconsistent phenomenon is the complexity
of the subjects studied. There were considerable differences
in the pretreatment characteristics in a study and between
studies, including severity of crowding, arch discrepancy,
vertical skeletal pattern, and other orofacial features,
which resulted in the wide range of individual
variations in tooth movement. One example was that
subjects with blocked-out and impacted second premo-
lars were included in the study of Schoppe.4 Since sever-
ity of crowding, pretreatment incisor position, FMA
angle, and individual response can influence the distance
of incisor movement,11-13 it would, therefore, seem to be
American Journal of Orthodontics and Dentofacial Orthopedics Chen et al 771
Volume 138, Number 6

impossible to predict the incisor movement in a patient Table I. Pretreatment and posttreatment variables
according to the average data obtained from a group Before treatment After treatment
of subjects with various craniofacial features, as Significance
suggested by previous authors.8,14,15 Variable Mean SD Mean SD (P value)
To observe tooth response, it is appropriate to study Age at start (y) 16.1 4.3
patients with normodivergent facial type, mild or no Crowding (mm) 2.0 1.3
crowding, and Angle Class I relationship. In hyperdiver- SNA ( ) 84.1 4.2 83.6 4.3 0.1204
gent or hypodivergent subjects, the skeletal pattern SNB ( ) 80.6 4.5 80.3 4.8 0.4037
ANB ( ) 3.5 1.9 3.3 1.5 0.315
might affect horizontal tooth movement. In those with
FMA ( ) 29.4 6.8 29.5 7.2 0.7141
severe crowding, most extraction space would be used OP/SN ( ) 18.1 5.6 18.3 5.6 0.8383
to reconcile arch length discrepancy, and then the space U1/PP ( ) 59.1 8.2 68.0 10.0 0.0002*
distribution pattern would be affected by the amount of U6/PP ( ) 78.5 10.1 80.4 5.2 0.429
residual space and the mechanotherapy used in releas- U1/NA ( ) 25.3 5.9 18.5 6.6 0.0009*
U1-NA (mm) 5.0 2.3 2.5 1.9 0.0003*
ing crowding. Class I malocclusions were selected to
L1/MP ( ) 93.4 8.1 88.3 6.5 0.005*
eliminate excessive molar movement involved in the L6/MP ( ) 84.3 5.2 80.3 6.0 0.003*
treatment of Class II and Class III malocclusions. L1/NB ( ) 31.6 5.2 26.8 5.0 0.0051*
Therefore, this study was undertaken to determine L1-NB (mm) 7.4 1.6 5.3 1.7 0.0003*
the anterior and posterior dental changes in a group of U1/L1 ( ) 118.6 9.2 130.4 8.7 0.0003*
Upper lip to 2.7 1.4 1.5 2.0 0.031*
patients with mild crowding, slight dental protrusion,
E-line (mm)
and Angle Class I relationship treated with 4 second Lower lip to 4.1 2.1 2.1 2.3 0.015*
premolar extractions and preadjusted appliances. E-line (mm)
Z angle ( ) 79.4 3.7 76.6 3.7 0.032*

MATERIAL AND METHODS Student t test; *P \0.05.

This study was retrospective and included 26 sub-

jects: 15 boys and 11 girls, with an average age of 16
years 1 month at the commencement of treatment and
an average treatment time of 2 years 1 month.
All subjects were selected from patients referred to the
Department of Orthodontics, West China Stomatology
Hospital, Sichuan University, who fulfilled the following
criteria: (1) skeletal Class I and dental Class I malocclu-
sion, (2) mild arch crowding (0-4 mm), (3) slight dental
bimaxillary protrusion, and (4) normodivergent face
type (24 \FH-MP \34 ).
This clinical research was approved by the institu-
tional ethics review board of Sichuan University. The
pretreatment characteristics of the subjects are shown
in Table I. All patients were diagnosed and treated by
1 operator (D.B.) with a 0.028-in slot preadjusted
edgewise appliance (Roth) and sliding mechanics. The
treatment protocol was as follows: 4 second premolars
were extracted as part of a comprehensive orthodontic
treatment plan. All teeth mesial to the second molar
were bonded. A preadjusted edgewise appliance was
used for all patients. After aligning the maxillary and
mandibular dental arches with sequentially changed
continuous nickel-titanium archwires, maxillary and
mandibular 0.018 3 0.025-in stainless steel wires with
a reverse curve of Spee were placed with a depth of about
3 to 4 mm. The crown labial torque in the maxillary pos-
terior and mandibular wires was eliminated, but main-
tained in the maxillary anterior part. The crown labial
torque was about 10 in the maxillary central incisor
region. On these wires, intra-arch nickel-titanium coil
springs were used to close the remaining spaces, and in-
terarch Class II elastics were used when required to har-
monize the molar relationship. After all spaces were
completely closed, the second molars were included in
the archwire, and the whole arches were aligned again.
No posterior anchorage enhancement appliance (eg,
temporary implant anchorage or transpalatal arch) was
used. Normal incisor overbite and overjet and posterior
neutral relationships were achieved at the end of treat-
ment. One patient’s records are shown to illustrate the
pretreatment orofacial features and treatment changes
(Figs 1 and 2).
Patients whose second premolars were extracted for
other reasons, such as severe caries, periapical lesions,
or blocked out or impacted teeth, and who had systemic
diseases that could affect bone metabolism were
excluded from this study.
Lateral cephalometric radiographs were taken of all
patients before and after treatment. The cephalograms
were obtained on the same radiographic unit (Orthopanto-
mograph OP 100D, Instrumentarium, Tuusula, Finland)
under standardized conditions.
The amounts of incisor and molar movement were
assessed by superimposing the maxilla on ANS and
the palatal plane (ANS-PNS), and the mandible by the
structural method.16,17 Retraction of the maxillary and
772 Chen et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2010

Fig 1. Pretreatment records of a 22-year old woman with mild crowding, slight bimaxillary protrusion,
and an Angle Class I molar relationship.

mandibular central incisors was measured on the as the intersection of 2 lines that coincides with the tooth
posttreatment occlusal plane, from the projection point axis before and after treatment (Fig 3).
of the maxillary and mandibular central incisors’ edge
and apex. The degrees of maxillary and mandibular Statistical analysis
incisor tipping were measured from the angle between
Statistical analysis, including calculations of the
the long axis of the incisor and the palatal plane
means and standard errors of the mean for each variable,
and mandibular plane, respectively. Molar movement
was conducted with SPSS software (version13.0, SPSS,
was measured from a perpendicular between the
Chicago, Ill).
posttreatment occlusal plane and the most mesial
Ten randomly selected cephalograms were retraced
point on the molar crown and the mesial apex. The
and measured twice 4 weeks apart. Results of the paired
degrees of maxillary and mandibular molar tipping
Student t test showed no significant difference between
were measured from the angle between the long axis
the 2 sets of measurements at the 95% CI.
of the mesial root and the palatal plane and
mandibular plane, respectively (Fig 3). All tracing
and measuring work was done by the same operator RESULTS
(K.C.). The posttreatment cephalometric measurements are
The center of rotation of the incisors can be deter- shown in Table I, demonstrating that the problems of
mined by the method of Christiansen and Burstone18 dental and soft-tissue protrusion were solved, but there
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
Fig 2. Posttreatment records of the same patient who had 4 second premolar extractions.
was no remarkable change in the sagittal and vertical
skeletal structures.
The average maxillary central incisor movements
were 3.3 mm palatally at the edge and 0.5 mm at the
apex. The average crown palatal tipping was 8.9 . The
maxillary first molar was moved mesially by averages
of 3.2 mm at the crown and 2.2 mm at the apex, with
a mean value of 3.8 of mesial crown tipping.
The mandibular incisor was moved by averages of
2.9 mm at the edge backward and 1.4 mm in the apex,
and was tipped lingually an average of 5.1 . The man-
dibular first molar had mean mesial movements of
3.4 mm at the crown and 4.6 mm at the apex, and
a mean distal crown tip of 4.0 (Table II, Figs 4 and 5).
In the maxilla, incisor retraction took up 50.4% of
the residual space, whereas in the mandible 46.2% of
the remaining space was occupied by incisor retraction.
The space was distributed to the anterior and posterior
segments approximately equally (Fig 6).
Chen et al 773
The maxillary central incisor’s rotation center was
located –4.3 to 12.0 mm apical to the apex, and the man-
dibular central incisor’s rotation center was located 0.9
to 25.3 mm apical to the root apex (Fig 7).
DISCUSSION
It is remarkable that many studies reported wide
ranges of individual variations in incisor changes and
molar movements.1,3,4,8,11,12,14,15 Thus, the average data
could not be directly used to estimate likely tooth
position changes in a patient. In this study, from
a number of patients who were treated with 4 second
premolar extractions, we selected those with similar
malocclusions and treatment modalities. That enabled
creation of a more homogeneous group, compared with
those in the previous studies, and therefore made the
results applicable to further estimation in individual
patients.
774 Chen et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2010

CR Table II. Distances of tooth movement and tipping

PP ANS
Crown Apex Tipping

Tooth Mean (mm) SD CV Mean (mm) SD Mean ( ) SD

OP U1 3.3 1.7 0.52 0.5 1.1 8.9 3.1

L1 2.9 1.4 0.48 1.4 0.9 5.1 5.1
U6 3.2 1.1 0.33 2.2 1.1 3.8 3.3
OP L6 3.4 1.4 0.41 4.6 2.0 4.0 3.7

Positive numbers indicate mesial movement and tooth-axis clockwise

rotation; negative signs indicate distal movement and tooth-axis
counterclockwise rotation.

CR anchorage. We did not intend to investigate the limit

Fig 3. The maxilla was superimposed on the palatal
plane at ANS. The mandible was superimposed by the
structural method. Tooth movement was measured on
the posttreatment occlusal plane. The geometric posi-
tion of the incisor’s center of rotation was determined
by the intersection of 2 lines that coincided with the tooth
axis before and after treatment.
Schoppe4 reported on 12 subjects, but there was no-
table variability in the malocclusions and the appliances
used to treat them. Some patients with blocked-out and
impacted second premolars were included. Some au-
thors did not even mention their selection criteria;
this made it impossible to determine the patients’
before-treatment features.3,8,11,12 For this study, we
selected patients with mild crowding and slight dental
protrusion, and individual variations were avoided to
the greatest extent. Therefore, although the sample
size was relatively small, the treatment modalities
were comparatively standardized. The results under
this condition can reflect the true tooth response to 4
premolar extractions. Compared with those of the
previous studies, the individual variations in this study
were so small that the data can be used as guidance
when treating patients. We introduce the coefficient of
variation (CV), a parameter measuring the dispersion
of a probability distribution, to compare individual
variations in this study with those of previous studies.
Ong and Woods11 reported a maxillary incisal tip
change of 1.6 mm with a CV of 100% (1.6/1.6). In the
study of Shearn and Woods,12 the mandibular incisor’s
retraction relative to the APog line had a much higher
CV of 580% (2.9/0.5). In this study, all CV values of
tooth crown movement were less than 1, reflecting com-
paratively small individual variations.
Undoubtedly, all patients treated in our study could
have been treated in other ways—eg, first premolar
extraction or nonextraction with temporary implant
for retracting incisors, but to introduce the general
rule of tooth movement after 4 second premolar extrac-
tions with the most commonly used mechanics and the
principle of simplicity in orthodontic treatment. In our
study, a reverse curve of Spee wire and crown labial tor-
que in the maxillary anterior part were used to control
incisor labial inclination during retraction. Zigzag
elastics (Class II elastics and intra-arch elastics) were
applied to close the remaining extraction spaces and
harmonize the molar relationship. The treatment results
proved that this force system is successful in treating
patients with slight dental protrusion with 4 second pre-
molar extractions, and in controlling incisor position
and inclination appropriately at the same time.
The posttreatment occlusal plane was used as the
reference plane to measure the amount of tooth move-
ment in this study. In previous studies, some other
craniofacial reference systems, including the PM, SN,
and NPog lines, were used. The major deficiency in
these systems is that relating jaws to these cranial refer-
ence planes introduces inherent inconsistencies. These
inconsistencies arise from variations in craniofacial
physiognomy, including the sagittal spatial relationship
of nasion relative to the jaws and the rotation of the jaws
relative to the cranium.19 On the contrary, relating the
dentition to the occlusal plane will definitely not affect
the measurement of tooth movement and thus provides
a reliable method to assess that. Moreover, the occlusal
plane is clinically relevant and user friendly.20 The
results can also be used for diagnosis and treatment
planning directly on the models.
The average changes in the anteroposterior posi-
tions of the incisors in this study exceeded those re-
ported in previous studies.3,4,8,10-12,14 In our subjects,
the maxillary incisor was retracted 3.3 mm, and the
mandibular incisor was retracted 2.9 mm. Kim et al10 re-
ported comparable but a bit smaller results. Subjects
from the 2 studies had similar dental discrepancies
and pretreatment incisor labial inclinations. But in the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
2.2 0.5
OP
3.2 3.2
3.4 2.9
OP
4.6 1.4
Fig 4. Tooth movement measurements relative to the
posttreatment occlusal plane.
study of Kim et al, space was closed purely by intrajaw
elastics; thus, maxillary incisor anchorage loss was
decreased and resulted in less retraction. The smaller
retraction of the maxillary incisors in other studies
could be explained by the greater dental discrepancies
(4-7 mm) in their samples.3,4,8,11,12,14 Less space after
releasing crowding led to less incisor retraction.
The maxillary and mandibular incisors lost part of
their labial inclination during retraction. This finding
corroborates the previous data of Schoppe4 and
Logan.14 The fact that the rotation center had a highly
variable position indicated that the tipping movement
was under proper control to achieve better incisor
inclination on an individual basis with a similar force
system. Proper incisor inclination is crucial for an es-
thetic smile.21 Chinese people have a relatively convex
facial profile, and the incisor labial inclination is greater
compared with that of white people.22 That requires
proper incisor labial inclination to be maintained after
treatment to accommodate to the facial profile. How-
ever, a straighter and more retrognathic profile is the
preference of most people, so incisor inclination should
be properly reduced during retraction.23 Meanwhile, the
incisors were only prescribed to a minimal distal repo-
sition in patients with slight dental crowding and protru-
sion. Because of the play between the wire and braces,
crown labial torque was applied in the maxillary incisor
region to prevent too much crown palatal inclination
and unwanted distal movement.24 The result proved
that archwires with a reverse curve of Spee and zigzag
elastics can precisely and efficiently control incisor
retraction after 4 second premolar extractions.
In our study, there were mean molar mesial move-
ments of 3.2 and 3.4 mm in the maxilla and the mandi-
ble, respectively. These data were consistent with other
authors’ reports3,4,8,11,12,14 except for that of Kim et al.10
Kim et al10 reported greater mesial molar movements,
Chen et al 775
59.1
PP
68.0
OP
OP
84.3
93.4
80.3
88.3
Fig 5. Tooth tipping measurements relative to the pala-
tal plane in the maxilla and the mandibular plane in the
mandible.
which might stem from the greater than average facial
divergence at the start of treatment that could have
increased this movement during space closure.
In our sample, the extraction space was approxi-
mately equally taken up by the anterior and posterior
segments. In a study on various premolar extractions,
Williams and Hosila7 found that the anterior segment
occupied 66.5% of the extraction site in patients who
had 4 first premolar extractions, whereas the percentage
was 56.3% in those who had maxillary first premolar
and mandibular second premolar extractions. It is
widely accepted that anchorage potential is highly re-
lated to the area of root surface involved.8 According
to this rule of thumb, the proportion in patients with 4
second premolar extractions should be expected to be
less; this was proved by our study. Kim et al10 obtained
a smaller percentage of incisor occupation (44.5%)
because of greater than average facial divergence.
Meanwhile, our results on space distribution were quite
different from those of some previously published
classic articles about patients with 4 second premolar
extractions; they agreed that the extraction sites were
taken up mostly by the molars instead of the anterior
teeth.3,4,8,11,12,14 In our study, although crown labial
torque was applied to the maxillary anterior region,
the molars took up only half of the extraction sites.
This might suggest that molars cannot move mesially
as much or as easily as we expected, and more anterior
anchorage reinforcement should be considered for
more molar forward movement when a second
premolar is removed.11
The change of the facial skeletal vertical dimension
after premolar extraction would be essential to an es-
thetic outcome.25 In this study, no significant difference
776 Chen et al
49.6% 50.4%
53.8% 46.2%
Fig 6. Extraction space distribution in the maxilla and
the mandible.
was found in the cephalometric vertical parameters
except for the height of the mandibular molar. The man-
dibular molar was extruded while moving mesially due
to the mandibular archwire with the reverse curve of
Spee and Class II elastics. The extruded molar
contributed to the maintenance of the skeletal vertical
dimension. The vertical position of the maxillary inci-
sors was well maintained for an esthetic smile arc,
which benefited from the intrusive force in the maxillary
wire with the reverse curve of Spee.
When these results are applied to individual patient
treatment, it should be remembered that this study only
provides the tooth movement pattern in a simple but
standard situation. However, this could serve as a foun-
dation for diagnosis and treatment in more complicated
malocclusions, if considering other influencing factors,
such as severity of crowding, pretreatment incisor
position, and vertical growth pattern.
CONCLUSIONS
From these results, the conclusions are as follows.
1. Extraction spaces are approximately equally taken
up by the anterior and posterior segments in pa-
tients with mild crowding, slight dental protrusion,
and Angle Class I relationship after treatment with
4 second premolar extractions.
2. Preadjusted edgewise appliances, accompanied by
wires with a reverse curve of Spee and zigzag elas-
tics (intra-arch and Class II elastics), can ensure the
smooth closure of the extraction spaces and proper
control of the inclination of the teeth.
3. Incisor anchorage should be reinforced to gain suf-
ficient forward molar movement, even for second
premolar extractions.
American Journal of Orthodontics and Dentofacial Orthopedics
December 2010
A
B
Fig 7. Position of the center of rotation. B indicates the
average position. The region between A and C is the
range of individual variation.
4. The posttreatment occlusal plane would be an ap-
propriate reference plane to measure tooth move-
ments in Angle Class I second premolar extraction
patients.
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