American Journal of ORTHODONTICS

Volume 65, Number 2,

February, 1974

ORIGINAL

ARTICLES

Second-premolar clinical practice

Newton de Castro

extraction

in

Rio de Janeiro. Brazil

he improvement of facial esthetics and the maintenance of an organized occlusion continue to challenge the orthodontist. Teeth and jaws are rarely matched in size and position, resulting in a malocclusion beyond hope of self-correction. In severe malocclusions, the orthodontist recognizes that the retention of all the teeth in a stable alignment for long periods is impossible. Thus, the extraction of certain teeth becomes an acceptable compromise in orthodontic practice. In some cases, however, extraction has failed to achieve its goal because of a historical insistence on selecting the first premolars for extraction despite clear clinical indications for not doing so. Newer clinical data suggest that other teeth than the first premolars are often the better choices for extraction. This article will show why the second-premolar extraction is mostly recommended in the average extraction case. It will also show that extraction of the second premolar in one arch and the first premolar in the opposite arch may constitute the treatment of choice in certain orthodontic cases.
Historical considerations

For some time, orthodontic philosophy was largely based on artistic concepts, with no thought given to anatomic, anthropologic, and functional relationships. Teeth were extracted simply to achieve more pleasant esthetic objectives. Not until some time later did orthodontists recognize the importance of each tooth in the dental arch. Five extraction compromises have evolved in orthodontic treatment: (1) extraction of the four third molars, (2) extraction of the four first molars, (3) extraction of the four second molars, (4) extraction of the two maxillary
115

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Am. J. Orthod. February 1974

Fig. and that Fig. Fig.

1. The human dental arch presents three two posterior segments. The transitional is, at the canine-first premolar contacting 2. The extraction extraction of a second premolar premolar in the

independent segments: area is located where area. in the middle area of the

one anterior segment the segments meet, posterior arch. segments.

3. The

of a first

transitional

of the

second molars, and (5) extraction of the four first premolars. The last choice has proved to be the most popular. No school has consistently advocated removal of the second premolars, although second-premolar extraction is not a new procedure in orthodontics. In 1949, the first article appeared describing the indications for such extraction, and these indications remain valid until today. Other papers followed,* 3 but two decades passed before orthodontists grasped the fundamental importance of tooth selection in patients requiring extraction.
Anatomic and anthropologic considerations

In spite of obvious variations, the dental arches of all mammals show clear anatomic and anthropologic similarities. From the standpoint of occlusion and harmony of tooth size, the dentitions of all mammals may be thought of as an arrangement of three independent, autonomous segments-an anterior segment ending at the two canines and two posterior segments beginning at the first premolars and ending, respectively, at the right and left third molars, if present (Fig. 1). When a second premolar is extracted in the middle of the posterior segment, this segment only is shortened. However, when a tooth is removed at the point where the segments meet, that is, in the first premolar area, not only is the

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posterior segment affected but the transitional area is also disturbed (Figs. 2 and 3). Clinical experience has shown that extraction at that point where the segments meet is more disturbing to the integrity of the natural dentition as a functional machine than is extraction within a segmental unit. The segment junctions, or transitional areas, are functionally important. When the first premolar is present, transitions in form and function from the anterior to the lateral segments are gradual. When that tooth has been extracted, however, the changes are more abrupt. Since the first premolar is so important to the organized occlusion of man, it is clear that the orthodontist should try to save this tooth whenever possible.
Material and method

The sample included observations from 100 consecutive cases of Class I, Class II, and some Class III malocclusions in the mixed and permanent dentitions with various growth patterns. In addition, 200 cases with normal occlusion, provided by other orthodontists, were examined. From our sample, eighty-seven patients were treated with second-premolar extraction and thirteen were treated with alternate extraction plans. This article will illustrate the more pertinent and interesting second-premolar-extraction cases, Basically, all cases were treated with the edgewise mechanism. Edgewise brackets with 0.018 inch slots were used with progressive banding. Generally, light round wires are placed first for tooth alignment but as soon as possible they are replaced with rectangular wires to close the extraction spaces and finish the case.
Findings

Our studies have brought into focus some tentative truths concerning secondpremolar-extraction cases which seem true at this time. These tentative truths were complemented and enriched by the valuable experience of several clinical orthodontists who have shared mutual observations. There are some good and old tested principles upon which there is an almost general agreement among most orthodontists : 1. Most orthodontists agree on second-premolar extraction in cases presenting some crowding when they deliberately want to move the molars forward more than 2.5 mm. on each side, perhaps, from 3 mm. to 4.5 mm. or, in other words, they want to slip or lose part of the anchorage. 2. Most of us agree that in the average extraction case, the patient does not need a great change in his facial profile. If the incisors can be held where they are, the second-premolar extraction will provide the needed space for alignment. 3. Many orthodontists agree that arch-length discrepancies of 5 mm. or more are hard to hold permanently without extraction of teeth except in some cases of rare growth response. When there is an arch-length discrepancy of 5 mm. or more, with a good profile to start with, extraction of the second premolar is indicated.

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Am. J. Orthod. February 1974

- - - - --15.6

Fig.
original

4.

Superposition ANB angle

of of

the 6

tracing degrees

of has

Class

II,

Division little in the

1 malocclusion decision to

in extract

which

the

weighed

second

premolars.

Fig.
bite pad

5.

Superposition In

of spite

the of

tracings the large

of

a high-angle base of

case 10

presenting degrees, notice

crowding the big

and

open-

symptoms. covering

apical

soft-tissue

pogonion.

A second-premolar-extraction

case.

4. Posterior crowding of second and/or third molars or impactions in the arch should also be considered as arch-length problems. Second-premolar extraction may solve this problem much better than first-premolar extraction. A sharp knife always cuts better than a blunt one. Like the keen craftsman, the orthodontist must always sharpen his most important tools, his diagnostic tools. Appliances are only devices. They obey our fingers. But to work out a good treatment plan, the orthodontist must have some basic concepts, and he must also begin with the end in mind,4 that is, knowing where he wants to end up and with clear objectives. In this way, he will know where he is during treatment as well as how to get from there to the final planned goal. In order to set clear and specific objectives in this work, we have arranged the orthodontists diagnostic tools into three separate group : A. Dentoskeletal diagnostic tools. B. Adjustment diagnostic tools. C. Soft-tissue diagnostic tools. Dentoskeletal diagnostic tools. For a long time much emphasis has been placed on the interrelationship of hard dentoskeletal tissue measurements in orthodontics. The final ANB angle has become an important tool for the orthodontist. Treatment plans are worked out in such a way as to allow variations in the position of the lower incisors according to this angle at the time of retention. If a good mandibular growth response is forecast, regardless of the original ANB angle, the patient may be helped with the second-premolar extraction (Fig. 4).

Second-premolar
,, I',' .

extraction

119

J. G.O

I I I

Fig. 6. A, Tracings of a severe high-angle Class I dysplasia showing marked deformity in the skeletal pattern. 6, Superposition of the tracings before and after treatment. Notice the extensive development of the nose and the hard chin. Extraction of a first premolar in this case would result in a face that was too flat. A second-premolar-extraction case.

The orthodontist has become aware of the contribution of the hard bony chin to the facial features of his patients, but sometimes he forgets that when treating a malocclusion of teeth he is also treating a face. The hard bony chin is covered with a variable cap of soft tissue, and it is important for the orthodontist to be aware of this when he is going to decide which teeth to extract. For a long time, the mandibular plane angle has been a useful diagnostic tool. In high-angle cases, the orthodontist must stretch whatever condylar growth the patient may have and make do with it. Thus, in a real sense, the orthodontic treatment in these cases involves a combined problem of growth conservation and a strategic treatment program. In a high-angle case presenting crowding and open-bite symptoms, the extraction of second premolars encourages freer mesial movement of the posterior teeth. It affords a good therapeutic strategy, provided it is accompanied by good mechanics for not increasing the facial posterior height (Figs. 5 and 6). ~ldjusfme)tf dirrgnosfic fools. The adjustment diagnostic tools are those factors which may be modified more freely by the orthodontist; in other words, these are the tools that are, to a certain extent, under the control of the orthodontist. First of all, we should mention arch-length discrepancy, Clinical experience has shown that by uprighting the mandibular buccal segment, which is actually tipped forward in many Class II, Division 1 malocclusions, plus proper bracket angulation, it is possible to gain as much as 1 to 5 mm. in arch length. If this gain is still inadequate and if the facial features of the patient do not require drastic change, as it is true in most cases, extraction of the second premolars is indicated. Closure of space following second-premolar extraction is more rapid than after first-premolar extraction because the former generally allows the

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Am. J. Orthoc February 19 7

Fig. and

7. Models of an average 3 years after all retention

was

second-premolar-extraction discontinued.

case.

Casts

before

treatment

orthodontist more usage of Class II mechanics to slip some posterior anchorage. In most average orthodontic cases, little retraction of the anterior segment is required. Thus, undesirable facial distortion is prevented. In all of these cases, extraction of the second premolar is indicated (Figs. 7 to 14). Extraction of the second premolars also limits the depressing action on the mandibular incisors and canines. This occurs because the eight anterior teeth will resist an intruding force more readily than will the canines and incisors alone. When the four first premolars have been removed, it is difficult for the

Volume Number

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Fig. 8. Photographs
discontinued.

of the

same

case

before

treatment

and

3 years

after

all

retention

was

orthodontist to stop this intruding force on the mandibular incisors and canines. It is easier for him to place the mandibular canines in their correct axial positions after extraction of the second premolars. This is true because the extraction spaces are distal to the first premolars. We have also found it easier to maintain a correct mandibular canine width following extraction of the second premolars. Moving back the eight anterior teeth as a unit helps to avoid driving the canines too far back into a larger and more unstable anterior segment and also to avoid tipping the canines into the extraction spaces. The occlusal plane is also an important diagnostic tool. We have found that in patients with a high occlusal plane angle and open-bite symptoms, extraction of the second premolars is to be preferred, because this procedure tends to move both maxillary and mandibular buecal segments farther forward, resulting in a closing of the bite (Fig. 6), The overbite, the overjet, and the bite closure are interdependent tools which the orthodontist may change, if necessary. In most patients requiring bite closure and in most open-bite symptoms, the extraction of the second premolars is desirable, since it tends to bring the maxillary and the mandibular molars forward. In Class III symptoms, a further extrusion of the maxillary and mandibular molars may even be indicated in order to rotate the mandible down-

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Am. J. Orthod. lwwuarg 1974

Fig. 9. treatment.

A, Superposition B, Superposition

of the tracings of the same case of the tracings on the maxilla

before and

treatment and on the mandible.

after

active

and backward. In these cases, extraction of the second premolar is indicated. Of course, if the patient presents a high mandibular plane angle, these objectives must be reformulated. Extraction of the second premolars fulfills, in a better way, the concept of canine protection. This is true because the canine-first premolar combination provides better function than the canine-second premolar combination, The former provides proper cusp heights to assure correct canine rise during the protrusive masticatory cycle (Figs. 15 and 16). Some have claimed poor contact between the mandibular first premolar and the lower first molar in cases requiring extraction of the second premolars, but this is not a valid objection. This problem could be overcome easily by a simple rotation of the mandibular first premolar contact point, depending on the bodily lateral side shift of the mandible. The maxillary first premolar, however, should be overrotated mesiolingually to produce the best contact with the maxillary first molar (Figs. 17 and 18). Finally, it is believed that we should reformulate our concept that all orthodontic results should last a lifetime when we know that even good nonorthodontic mouths very rarely retain their integrity of form and stability until adulthood. Yet, clinical judgment has shown that, when extraction of the second premolars is indicated, stable results are achieved. This procedure prevents an excessive lingual movement of the mandibular incisors; it causes little depression of the mandibular canines and incisors; it does a good job of maintaining the correct mandibular canine width and its proper axial positions ; it provides a nice buccal interdigitation; and, finally, it leads to a good function of the teeth. With these considerations in mind, it appears that extraction of the second premolars gives the orthodontist a good opportunity to achieve satisfactory results. Soft-tissue diagnostic aids. Some faces are beautiful; others are not. This has
ward

Fig 1. 10. A, Before-treatment models of an average Class II, Division 2 malt ssenting muscular problems and tongue-thrust habit. A second-premolar-extracti! prl of the same patient at the age of 14 years 4 months in the retention B, Models models of the same case when the patient was 20 years 1 month C, Follow-up all retention had been discontinued for many years. Notice the nice interdi Wk ren of teeth. (Courtesy of Reed A. Holdaway.)

on c ase. pel ,iod. of 1 w, igita Ition

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Am. J. Orthod. February 1914

fig. in the the

11.

A,

Photographs started. period of the of Reed patient between A.

of Notice when

the the the at the the

same rather patient age

patient good was of and 20 lower

at profile 14 years

the

age of the 4 and

of

12

years B, of has and

8 months, Photographs age. the C, chin improved.

before taken Follow-up Notice complex.

treatment photographs

had retention

patient. months Profile the lips

years

1 month. sulcus

relationship of

upper

(Courtesy

Holdaway.)

long been apparent, but it is difficult to analyze why these variations exist. For many years orthodontists attempted to analyze malocclusions by directing their attention almost exclusively to the hard dentoskeletal morphology of the face, although they once were taught the importance of facial harmony and ba1ance.5 Holdaways facial esthetic line, like any line, has two ends. The upper end of the line is on the greatest prominence of the upper lip, which the orthodontist

Volume Number

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extraction

125

Fig.
all

12.

A,
The

Superposition had chin. 6, The been H angle

of moved

the from

tracings for of the

of

the to

same ANB 2.5 of the the Reed

patient changed degrees. same lower

before from Notice case incisors on

treatment 3.5 the the in degrees good maxilla almost

and to hardand the

after 1.5 and on same

retention

discontinued

years. tracings to keep of

degrees. soft-tissue the vertical

10 degrees decided

Superposition operator had

mandible. and

anteroposterior

positions.

(Courtesy

A. Holdaway.)

could change through treatment. The lower end of the line is on the greatest prominence of the soft tissue chin, which may change its position by growth but the orthodontist cannot modify it. Of course, he could change to some extent the Y axis, which could be closed or opened by treatment, and the mandible may rotate through the extrusion of molars. That is what the orthodontist has to plan before starting treatment. The most important soft-tissue measurement tool for the Utah Study Group is the upper lip sulcus, which is the deepest point of the soft-tissue curvature under the nose. According to Holdaways clinical experience,6 this upper lip sulcus measurement should be 5 mm., ideally, with a range of 2 mm. (Fig. 19). Of course, very thin lips may allow this measurement to go down to 3 mm. with no loss of normal facial expression. On the other hand, thicker lips would allow 7 mm. contour better than 5 mm. Short and long lips also tolerate smaller and longer measurements, respectively. Adolescent boys with great forward growth of the mandible could tolerate a flatter upper lip contour than could adolescent girls. In some Class III tendency cases the mandible can tolerate a deeper upper lip sulcus (about 7 mm.). This will balance better with a strong chin button in these cases. Treatment should be planned to maintain a minimum but adequate upper lip contour. All these diagnostic softtissue measurement aids are extremely important to the orthodontist when starting treatment, for he has to decide whether or not to extract and which tooth to extract if the case needs a compromise treatment.

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Am. J. Orthod. February 1974

Fig. 13. showing

A, Before-treatment some crowding

models in the lower retention well

of

an arch.

average Class I deep-overbite A second-premolar-extraction been good discontinued. interdigitation. The bite has (Courtesy

case.

malocclusion B, Models and C.

of the same case after all the teeth seem to function Crockatt.)

had with

kept open of William

As a rule, both lips tend to return to their original unstrained or unstretched measurements in thickness and in length after treatment. Of course, the final positions of the upper lip and the upper lip sulcus do not immediately follow tooth movement. It takes them many months to settle in and get back to their original thickness and length, if they are adequate to start with. Thus, the final position of the upper incisors is determined by the final position of the upper lip after it has been settled in and after the bouncing back of all upper teeth has taken place. The final position of the lower incisors depends on the final position of upper and lower lips, planned before treatment has started plus the desired final position of the upper incisors (Fig. 20). The nose is the most difficult diagnostic tool to be forecast, since it varies

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extractiovt

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Fig.

14.

A, Superposition

of the

tracings

of the

same

case

before

and

after

treatment.

The

profile position mesial incisors.

did not change much. There was a deliberate opening of the Y axis. 6, Superof the tracings on the maxilla and on the mandible. Notice that there was more movement of the upper and the lower molars than substantial change at the (Courtesy of William C. Crockatt.]

during treatment time. One kind of nose may grow much during treatment while another may not grow at all (Fig. 6, B). For this reason, it is not a cvood reference for the esthetic line. Generally, noses do not make much difference are not too big or To the orthodontists plan of treatment, provided that they too small in relation to the other facial features, as long as the patient presents a nice upper lip sulcus contour. The nose is individual, and the orthodontist cannot change it. Finally, it might be pointed out that Reed Holdaway has incorporated these soft-tissue measurements to recheck the hard dentoskeletal analysis before the final objectives are set up. Then, he reverses this process of analysis and gives all consideration to how the patient is going to look at the end of treatment by working out the desired soft-tissue changes and determining from this what movements of teeth will be required to produce those alterations in the profile contours.
greatly Discussion

Anchorage preparation was first developed to eliminate part of the problems in Class II mechanics. Nevertheless, it was found that, by leveling off the mandibular arch, by preparing anchorage, by increasing the tip-back bends, and by using Class III mechanics, more was lost in root position than was gained in crown position. This problem soon was solved by the use of angulated brackets and tubes in the mandibular arch, together with the institution of Class III mechanics from the beginning of trea.tment. By these means, the roots were

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Am. J. Orthod. February 1974

Fig. 15.
Contact

Composite points Composite that contacts are

drawings about drawings are not the

of same

the

upper height. upper as

and

lower

cuspid-first

premolar

combination.

Fig. 16.
Notice

of the as good

and in the that

lower

cuspid-second combination. contact premolar of area the

premolar

combination.

previous

Fig. 17.
upper rotation mesiolingually. and

Composite lower of the first

drawings molar-upper first lower

showing premolar

a good lower an first

could upper

be

gained just first by

in the simple premolar

and and

combination

overrotation

Fig. 18.
combination.

Composite Compare

drawings these

showing contact areas

the

contact with the

areas ones

of shown

first

molar-second in Fig.

premolar

17.

held in position while the crowns were tipped distally. In the incisor area, early orthodontic techniques resulted in more lingual movement of the anterior teeth than was usually necessary. At that time, many orthodontists were taught intricate space-closing techniques which aimed at retruding the anterior teeth without mesial displacement of the buccal segment in extraction cases. The implication is clear that the chief emphasis was placed on maximum cases. Some orthodontists, however, applied this technique to the average orthodontic case. When the general rule for maximum cases is followed in all extraction cases, a high percentage of unsatisfactory esthetic results occurs. These disappointments led some operators to suspect that extraction of the four first premolars was not the best choice in all cases. Excessive retrusion of the maxillary and mandibular incisors resulted in an appearance as poor as the excessive labial protraction that. had existed before treatment. In maximum cases, the

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Fig. 19. An ideal face sulcus is about 5 mm. Fig. may 20. If we divide only change

according to Holdaways deep, which helps give the human profile into 3, 4, 5, and 6 during

esthetic that face treatment.

concepts. Note that a satisfactory profile. segments, we

the see

upper that

lip we

several

morphologic

segments tracing the ratio (Courtesy

Fig. 21. Original represented by ruined this face.

of a case with Class 1:7. If the operator of Wynn Anderson.)

I symptoms. had extracted

Note the protrusive in this case he

tendency would have

results were satisfactory, but in the great majority of average cases the patient would have been better off without treatment. Of course, these orthodontists believed that they were providing a desirable service. They had been taught to believe that. Clinical orthodontists have since found that it is possible to discover fallacies in long-settled philosophies of treatment. They have come to realize that science is not so much a search for truth as a search for errors-that the final truth is unattainable and that one must get along with a set of tentative truths that are good at certain times for certain purposes. Thirty years ago orthodontists were taught that, following extraction of the first premolars, canines could be (sometimes intentionally) tipped distally into the extraction spaces. But this was accompanied by excessive lingual inclination of the maxillary and mandibular incisors, resulting in dished-in profiles. Today, many clinicians believe that it is basically fallacious to move the mandibular incisors too far back too early in treatment before the growth tendencies of the individual patient are understood. If a mouth is prepared for more growth than it is destined to get by setting the incisors too far back, the orthodontist is faced with two equally undesirable alternatives. Either too much headgear traction must be used to push the maxillary teeth back to match the mandibular teeth, resulting in poor esthetics, or the case is finished in a kind of end-to-end occlusion. Ultimately, the mandibular arch may move back, leading to a partial Class II condition after retention.

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Am. J. Orthod. Februarg 1974

There are other reasons for dissatisfaction with the conventional philosophy routinely extracting the four first premolars in Class II, Division 1 malocc]usions. Most of these cases present with a pronounced overjet. If, following firstpremolar extraction, the orthodontist proceeds to retract the mandibular canines and incisors as much as he believes necessary-which sometimes is too much-a greater overjet than the original one is created. This new problem may be solved only by moving the maxillary teeth farther back than in the original malocclusion; otherwise, the orthodontist must rely on a phenomenal growth of the mandible, which does not usually occur. Thus, he is unable to solve the anteroposterior relationship of the teeth permanently, although in some cases a temporary repositioning of the mandible may appear to have solved the problem. Many times, however, there is insufficient growth of the condyles to put the mandible where it should be. At this stage of treatment, the orthodontist removes the bands. Then the mandible may begin to relapse, leading to a kind of end-to-end molar relationship. The goal of treatment has proved unattainable because of insufficient mandibular growth. Furthermore, it may be necessary to force the maxillary teeth too far back, and so much cooperation is demanded from the patient that treatment fails. Another risk is an extrusion of the maxillary first molars caused by too much distal driving and the resultant rotation of the mandible, tipping of the occlusal plane, etc. Thus, the conventional setting of the mandibular incisors too far lingually in four-first-premolar-extraction treatment requires too much cooperation from the patient, too much growth, and too much good luck. This kind of treatment also tends to create too much vertical development, throwing the mandible down and backward. Even with the proper choice of headcap, the orthodontist may not be able to stop the vertical component of facial growth, although he may try not to make things worse. With all these considerations in mind, one can only ask why the orthodontist needs to move the mandibular incisors and canines too far back in the mouth. He doesnt. This procedure will not improve the patients smile or make his facial features more natural ; his teeth will not stay straighter. Why perform such an illogical act? To sum up, the four basic dangers of excessive lingual movement of the mandibular incisors are as follows: 1. Adverse effects on the facial contours (dished-in face). 2. The danger of producing a dual bite following insufficient mandibular growth. 3. The dangers inherent in preparing anchorage before undertaking other procedures. As we have seen, the mandibular teeth may be moved so far back in the mouth that satisfactory occlusion and esthetics cannot be achieved. 4. The excessive use of Class II mechanics is also basically dangerous. The orthodontist should move the six anterior teeth bodily to their proper positions over basal bone, not tip them beyond that position.8 All remaining spaces should then be closed by mesial movement of the buccal teeth. The establishment of mass anchorage in the buccal segment is indicated only when needed; when it is not needed, it may interfere with the attainment of a more
of

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nearly ideal result.s Indeed, since the establishment of mass anchorage in the buccal segment is not always needed, it follows that extraction of the second premolars is the treatment of choice in such patients. The first premolars are extracted when the orthodontist wants to preserve buccal anchorage more than anything else in difficult anchorage problems and when there is severe crowding of teeth.
Clinical procedures and indications for second-premolar extraction

It is unwise to set hard and fast rules about any orthodontic procedure, but we should do everything possible to ward off flattening of the profile of the patient since we believe that excessive lingual tipping of the anterior teeth is to be regretted as much as the excessive labial tipping often practiced in the past. Generally, in most cases requiring second-premolar extraction, soft-tissue distribution is associated with a satisfactory profile and with a rather good mandibular growth. In most of these cases a drastic facial change is not indicated. Although there are arch length problems in some cases, the faces of many of these patients would be ruined if first-premolar extractions were performed. Arch length consideration is not of much concern to the orthodontist in most second-premolar-extraction cases, since he may slip some anchorage in these cases. The orthodontist can recognize several characteristics which indicate a good or bad potential for more forward or more vertical vectors of growth tendencies. When such a tendency is favorable, although with some arch discrepancies, orthodontists are inclined to extract second premolars if necessary. This decision, of course, is based on the kind of mandible the patient presents when treatment begins. The type and the morphology of the mandible will show the marks of its behavior in the past, its present state, and its tendencies for the near future. We know, however, that to every rule in biology there are many exceptions. Many cases, for example, show a thin lower alveolar buccal process, and in these patients it would be futile for the orthodontist to attempt to drag the mandibular molars forward, particularly in adults. Therefore, we agree that it is wise to have a good look at the general aspect of the alveolar process routinely before deciding upon a final treatment plan. Even with favorable growth tendencies, no extraction whatever should be done in some cases, including second-premolar extraction, because this would cause a reduction of at least 3 degrees on the H angle and a flatter sulcus depth of the upper lip, resulting in profile deterioration (Fig. 21). We agree that some cases show a significant discrepancy in soft-tissue distrihution over the hard structures of the face in relation to the type and structure of pogonion and that this has a marked influence on the selection of teeth to be extracted. Two well-defined groups of discrepancy in soft-tissue distribution may be set apart. In the first, there may be little soft tissue covering an average pogonion or an elongated symphysis in spite of a 1 :l ratio of the pogonion to the mandibular incisors. The ANB angle may be normal, but the H angle generally is larger than it should be. Such cases illustrate the importance

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Am. J. Ortltod. February 1974

T. P. Q

Fig.
head Note end Fig. capping mm. H tion good

22. film the

left,
the and

Original H angle 6 years

tracing is 20 after

of degrees,

Class which The and

I malocclusion. is too the much. was balance [Courtesy nice case. H angle

Note

that from nose, of Reed how a

although

there of the to

is

2: 2 ratio,

Right,
of

Superposition

original at the

retention. growth

reduced

20
lips,

8 degrees. chin

excellent

mandibular

and

of treatment. 23. Note plane. of one

A second-premolar-extraction Original tracing covering straight Superposition premolar allowed with. profile of of a with the the Class I case could pogonion, original orthodontist

A. Holdaway.) thick ratio nose head profile, integumental of films. which 0.23:7.5 the Extractouching

left,
of soft

which lips,

shows an and final the the

tissue

pogonion

compensate and to the

exceptional tip original of the of

a rather

Right,
second to start

tracings

keep

was

Volume Number

65 2

Second-premolar
I. s.0

extraction

133

I ,
I,

,I ,,

T.
-

0.

Q
15.1 ::

t,

I. -18.1

L.0

Fig. ment

24. and

Superposition and the lower steep

of second

tracings premolars.

of plane.

a Class Note (Courtesy tracing

I malocclusion the nice of and Uprighting we did profile Reed one in this

showing which A. Holdaway.) made of the case. 2 years lower No

missing was kept

upper during

lateral treat-

incisors

mandibular of Division teeth in the of in this of symptoms. of the and second back profile the case tracings the

Fig.
case driving Note

25.
of the 26.

Superposition Class the upper balance Superposition extraction Superposition Class with of satisfactory. II upper fullness II,

original I malocclusion. were all

after buccal

retention segment was

in a and

that after of

extraction

necessary.

2 years tracing gave of It shows lips. lower The

retention. typical Class end II, result. from was The the occlusion covering This the end case of standpoint pogonion involved treatment Division 2 malocclusion. The

Fig. Fig.
but

alternate 27. with

a satisfactory a Class a first small original

I malocclusion integumental profile

capping improved. profile at

contrasting extraction seems

premolars.

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soft-tissue evaluation and also offer good opportunities for second-premolar extraction (Fig. 22). A second group shows a thick capping of soft tissue over pogonion, and this may compensate for an exceptional pogonion-mandibular incisor ratio (Fig. 23). We may also see a large chin button compensated by a larger final ANB angle or a small chin button requiring a larger capping of soft tissue. An organized occlusion plays an important part in the selection of teeth to extract. In some patients, the maxillary lateral incisors and the lower second premolars are congenitally missing. Here it would be difficult to maintain a good axial position of the maxillary canines with opened spaces mesial and distal to them if the maxillary first premolars were to be extracted. On the other hand, if we choose to close the spaces created by the missing maxillary lateral incisors, we have excluded the possibility of achieving canine protection because the maxillary first premolar is not an adequate stand-in for the canine in canine protection (Fig. 24). In some patients, only the mandibular second premolars are missing, and many orthodontists believe it wise to extract the maxillary second premolars, if necessary, to achieve better esthetics and better canine protection. Extraction may not be necessary at all in many Class II, Division 1 malocclusions showing mesial tipping of the mandibular buccal teeth after these teeth have been moved to their proper positions, provided the discrepancy is not excessive (Fig. 25). As for alternate extraction treatment, many orthodontists perform such extractions when the arch length problem is more acute in one arch and when soft-tissue analysis is taken into consideration. The first premolar may be extracted in one arch and the second premolar in the opposite arch. For example, in treating Class II, Division 2 malocclusion we should encourage the extrusion of the maxillary molars which, on the other hand, makes the correction of the Class II symptoms more difficult. To solve this problem, the orthodontist may extract the maxillary first premolar and the mandibular second premolars. The latter procedure would facilitate the mesial movement of the mandibular molars (Fig. 26). In some Class I cases, there may be little discrepancy in the maxillary arch, but nevertheless the profile may be improved as well as the relationship of the lower lip to the H plane (Fig. 27). These patients may show a small capping of soft tissue over pogonion. It is not uncommon for orthodontists to set all the mandibular teeth back, including point B areas, in these cases in order to create the illusion of a more prominent chin. Arch length problems, anchorage values, soft-tissue analyses, and growth tendencies have dictated our decision to extract the first premolar in one arch and the second premolar in the opposing arch, although, from the standpoint of an organized occlusion, such a solution is not ideal.
Final considerations

What is our general philosophy of extraction ? Earlier we have established that arch length

problems,

anchorage

values,

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Second-premolar

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growth tendencies, soft-tissue analysis, and an organized occlusion are the five main factors that guide our decision to extract. They have also dictated which tooth should be eliminated. We would like, however, to supplement these criteria with a few more considerations which may help the orthodontist reach his clinical decision : 1. Judgment of the future facial growth of the patient is important. A. Much near-future facial growth tendency is determined by the type of mandible presented, since most growth distortions leave their trace in the mandible. B. The type of alveolar process affects our decision to extract. When the process is narrow and offers little support for the teeth, we would tend to extract. When it is broad, there appears to be greater potential for mandibular growth and it will tolerate a little more rounding out, if necessary. 2. Tipping of teeth in the posterior segment. A. There may be little or no mesial tipping of teeth in the buccal segment-mostly in Class I, Class II, Division 2, and always in Class III malocclusions. These need no uprighting, and therefore no space would be gained by trying to tip them back. Thus, we are likely to resort to extraction if the patient presents arch length problems great enough to support this decision and if the profile needs improvement. B. On the other hand, most Class II, Division 1 malocclusions generally present some mesial tipping of the buccal teeth, allowing for an arch length gain of 3 mm. or more. In some of these patients, no extraction is necessary, provided growth tendencies are favorable. 3. Posterior crowding. For obvious reasons, the orthodontist usually is more aware of anterior crowding, but posterior crowding is just as important. Many times there is evidence of crowding or impaction in the area of the mandibular second and third molars, and this condition requires that the operator extract the premolars. The molars move forward faster if the second premolars are extracted. Sometimes crowding is present only in the maxillary arch, requiring that the orthodontist extract the second or third molars before beginning treatment. 4. Mechanical principles in case management. A. The amplitude of distal movement necessary to provide enough space for proper alignment must be determined. If the discrepancy is small, and if there appears to be some mesial tipping of the mandibular buccal teeth, some orthodontists simply move these teeth back to their proper positions without extraction. If there is no mesial tipping in the buccal segment, if the discrepancy is sufficiently great (5 mm. or more), and if the clinical analysis of future facial growth is not satisfactory, the orthodontist must extract.

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1974

5. Strategy of tooth movement. A. A particular kind of extra&ion may assist the orthodontist more than another type, making treatment easier for him and for his patient. B. If the orthodontist has some concept of how to handle a particular type of malocclusion, of how to avoid too much vertical growth of the posterior teeth, and of how to avoid rotation of the mandible, he will save much effort and he will achieve better esthetic results. C. By angulating and offsetting the positions of brackets and tubes, the orthodontist may speed the anchorage preparation (when indicated) and the closure of extraction spaces. This also helps the orthodontist achieve better root paralleling of teeth adjacent to the extraction spaces. Some orthodontists prefer to close spaces by tipping teeth and subsequently uprighting them (Begg technique). 6. The age, sex, and general growth of the patient. These well known and important factors do not need further consideration here. 7. Terminal growth. Terminal growth may help the orthodontist improve his clinical result if the case is concluded with an organized occlusion. On the other hand, terminal growth may jeopardize the result of years of hard work if the operator is not aware of it or if he fails to finish and retain his cases properly.
Summary

1. It is unwise to lay down hard and fast rules in orthodontics ; therefore, I have simply presented some tentative concepts to support my belief that secondpremolar extraction is to be recommended in average extraction cases. 2. Arch length problems, growth tendencies, an organized occlusion, anchorage values, and soft-tissue analyses are the principal factors that have dictated our decisions concerning which teeth to extract. Special emphasis has been placed on the last two factors. 3. I have shown what I believe to be the fundamental dangers in excessive lingual movement of the mandibular incisors and why it is equally dangerous to prepare anchorage first in every case and to use Class II mechanics routinely. I have then offered some suggestions to help the orthodontist plan his treatment safety.
The author wishes to express his appreciation to Dr. B. F. Dewel, to Dr. F. F. Schudy, to Dr. Warren R. Mayne, and to Dr. Roscoe L. Keedy for their encouragement and advice in the preparation of this paper. He would also like to express his gratitude to the Utah Study Group and particularly to Dr. Reed -4. Holdaway and to Dr. William C. Crockatt who have not only extended their generosity by providing cephalometric records but through the years have always discussed many ideas and concepts with the author. Some of these are set forth in this paper, and without them this work would not have been possible. Finally, to Mr. John C. Dyson my thanks for editorial assistance.
REFERENCES

1. Nance, 2. Dewel,

Hays N.: AX. J. ORTHOD. 35: 685695, 1949. B. F.: AM. J. ORTHOD. 41: 107-120, 1955.

Secod-premolar
3. Carey, C. W.: AM. J. ORTHOD. 38: 149-161, 1952. 4. Covey, S. R.: Begin With the End in Mind, Salt Lake City, 5. Angle, E. H.: Malocclusion of the Teeth, ed. 7, Philadelphia, Mfg. Co. 6. Holdaway, R. A.: Unpublished material. 7. Holdaway, R. A.: Personal communication. S. Nance, Hays N.: AM. J. ORTHOD. 33: 253-301, 1947.

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1971,

Deseret 1907, 8.

Book Company. 8. White Dental