ORIGINAL ARTICLE

Class II treatment efciency in maxillary premolar extraction and nonextraction protocols

Guilherme Janson,a Srgio Estelita Cavalcante Barros,b Marcos Roberto de Freitas,a Jos Fernando Castanha Henriques,a and Arnaldo Pinzanc Bauru, Brazil Introduction: In this study, we compared the efciency of nonextraction and 2-maxillary-premolar-extraction protocols in complete Class II malocclusion treatment. Methods: A sample of 112 records from patients with complete Class II malocclusion was divided into 2 groups with the following characteristics: group 1, comprising 43 patients treated nonextraction with an initial mean age of 12.63 years; and group 2, comprising 69 patients treated with extraction of 2 maxillary premolars with an initial mean age of 13.91 years. To compare the efciency of each treatment protocol, the initial and nal occlusal statuses were evaluated on dental casts with the peer assessment rating (PAR) index, and the treatment time of each group was calculated from the clinical charts. Treatment efciency was calculated by the ratio between the percentage of PAR reduction and the treatment time. PAR scores, treatment times, and treatment protocols efciencies of the groups were compared with the t test. Results: The 2-maxillary-premolar-extraction protocol had a smaller nal PAR score, a greater percentage of PAR reduction, and greater treatment efciency than the nonextraction protocol of complete Class II malocclusion. Conclusion: The 2-maxillary-premolar-extraction protocol has greater treatment efciency than the nonextraction protocol of complete Class II malocclusion. (Am J Orthod Dentofacial Orthop 2007;132:490-8)

t is known that treatment protocol and malocclusion severity can inuence the results, the duration, and, consequently, the efciency of orthodontic treatment.1-9 Because malocclusion severity is an inherent characteristic that cannot be controlled, efforts have been made to evaluate the inuence of treatment protocol on the efciency of orthodontic treatment.3,10,11 Efciency is dened as the capacity of producing the best results with the least time expense.12 It was demonstrated that complete Class II malocclusion treatment with 2 maxillary premolar extractions produces a better occlusal success rate than the 4-premolar-extraction protocol,6 because obtaining a Class I molar relationship in the 4-premolarextraction protocol requires more anchorage reinforce-

From the Department of Orthodontics, Bauru Dental School, University of So Paulo, Bauru, Brazil. a Professor. b Graduate student. c Associate professor. Based on research by the second author in partial fulllment of the requirements for the degree of master of science in orthodontics at Bauru Dental School, University of So Paulo. Reprint requests to: Guilherme Janson, Department of Orthodontics, Bauru Dental School, University of So Paulo, Alameda Octvio Pinheiro Brisolla 9-75, Bauru, SP, 17012-901, Brazil; e-mail, jansong@travelnet.com.br. Submitted, January 2005; revised and accepted, October 2005. 0889-5406/$32.00 Copyright 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.10.031

ment with removable appliances and more patient compliance than maintaining Class II molar relationship in the 2-maxillary-premolar-extraction protocol.2,5,6,13,14 Treatment time is also shorter in the 2-maxillary-premolar protocol than in the 4-premolar-extraction protocol15 because molar relationship correction, inherent to nonextraction and 4-premolar-extraction protocols, is considered to increase Class II treatment time.3,8,11,16 According to this rationale, it could be speculated that probably a 2-premolar-extraction protocol also has a better occlusal success rate and a shorter treatment time than a nonextraction protocol in complete Class II malocclusion patients. Although treatment results and treatment times have been compared between treatment protocols, the amounts of change in a time period have not been related to each other to evaluate treatment efciency. The purpose of this study was to test the following null hypothesis: complete Class II malocclusion treatment efciency is similar in nonextraction and 2-maxillarypremolar-extraction protocols. Therefore, occlusal results, treatment times, and efciency index values were compared between the 2 groups treated with these protocols.
MATERIAL AND METHODS

The sample was retrospectively selected from the les of the Department of Orthodontics at Bauru Dental

490

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School, University of So Paulo, Brazil; the les include 3592 documented and treated patients. Records and the initial and nal dental study models of all patients who initially had complete bilateral Angle Class II malocclusion (molar relationship) and were treated without extractions or with 2 maxillary premolar extractions and standard xed edgewise appliances were selected and divided into 2 groups. Sample selection was based exclusively on the initial anteroposterior (AP) dental relationship, regardless of any other dentoalveolar or skeletal characteristic. Additionally, the patients selected had all permanent teeth up to the rst molars and no dental anomalies of number, size, and form. Group 1 consisted of 43 patients (21 male, 22 female) treated nonextraction at an initial mean age of 12.63 1.45 years (range, 9.39-16.03 years). Thirty-six of these patients had Class II Division 1 malocclusions, and 7 had Class II Division 2 malocclusions. Group 2 consisted of 69 patients (38 male, 31 female) treated with extraction of 2 maxillary rst premolars at an initial mean age of 13.91 2.71 years (range, 9.42-27.08 years). Fifty-one of these patients had Class II Division 1 malocclusions, and 18 had Class II Division 2 malocclusions. Orthodontic mechanics included xed edgewise appliance, with 0.022 0.028-in conventional brackets and the usual wire sequence characterized by an initial 0.015-in Twist-Flex or a 0.016-in Nitinol, followed by 0.016, 0.018, 0.020, and 0.021 0.025 or 0.018 0.025-in stainless steel wires (all from 3M Unitek, Monrovia, Calif). Deepbite was corrected with accentuated and reverse curve of Spee. In the 2-maxillarypremolar-extraction patients, the anterior teeth were retracted en masse with a rectangular wire and elastic chains for overjet and Class II canine correction. Extraoral headgear was used to correct the Class II AP relationship in the nonextraction group, whereas, in the extraction group, an extraoral appliance was used to reinforce anchorage and maintain the Class II molar relationship. When necessary, Class II elastics were used in the nonextraction group to help obtain a Class I molar relationship; in the extraction group, this procedure was used to help maintain a Class II molar relationship. The patients records were used to determine initial age (IAge), sex, date of treatment onset, date of treatment completion, and total treatment time (TT). During this procedure, it was observed that 21 of the 43 patients (48.8%) treated without extractions received 2-phase treatment and used the combined headgearactivator appliance for 11.2 6 months before treatment with a xed appliance. On the other hand, 22 of the 69 patients (31.8%) treated with extractions of

maxillary premolars had the extractions because of the unsuccessful attempt of Class II malocclusion treatment without extractions. Because the nonextraction groups 2-phase treatment and the extraction groups delayed extractions could inuence the occlusal results and TT,17-23 the nonextraction patients were divided into 1and 2-phase treatment subgroups (subgroups 1A and 1B), whereas the extraction patients were divided into immediate-extractions and delayed-extractions subgroups (subgroups 2A and 2B). These subgroups were also compared to investigate whether 2-phase treatment and delayed extractions affect the results. The peer assessment rating (PAR) index24 was calculated on the pretreatment and posttreatment study models of each patient, according to the American weightings suggested by DeGuzman et al.25 Initial and nal occlusal characteristics were ranked by scores for molar and premolar AP relationship, overjet, overbite, midline, crossbite, and crowding to quantify the initial malocclusion severity (I-PAR), the occlusal treatment results (F-PAR), and the percentage of PAR reduction (PcPAR),3,7,26 which is a better estimate of occlusal improvement.10 Because the PAR index analyzes a set of occlusal characteristics at the same time and does not discriminate the participation degree of each in the total score, the posttreatment scores obtained for each PAR component were individually compared to determine the success rate achieved. Therefore, the PAR score at the end of treatment was again separated into its several components to allow an individual evaluation. The treatment efciency index (TEI) was evaluated by the relationship between PcPAR and TT in months, expressed as TEI PcPAR/TT. The TEI increased when a greater PcPAR was associated with a shorter TT. Initial and nal PAR scores were recalculated by the same examiner (S.E.C.B.) in the pretreatment and posttreatment study models of 30 randomly selected patients. The casual error was estimated by Dahlbergs formula (Se2 d2/2n), where S2 is the error variance and d is the difference between the 2 determinations of the same variable; the systematic error was calculated with dependent t tests, at P .05.27,28
Statistical analyses

Compatibility of the groups regarding the proportions of Class II Divisions 1 and 2 malocclusions and sexes was evaluated with chi-square tests. T tests were used to compare the groups regarding IAge, I-PAR, F-PAR, PcPAR, TT, and TEI. Because there was a statistically signicant difference in the IAges that could inuence F-PAR and TT,3,18,20,22,29-32 some patients were eliminated from both groups to match the

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Table I.

Results of independent t test between groups 1 and 2

Group 1 (n 43) (nonextraction) Group 2 (n 69) (maxillary premolar extractions) SD 1.45 7.67 5.62 31.38 9.74 1.32 .05. Mean 13.91 23.95 2.42 88.87 26.99 3.78 SD 2.71 7.40 2.88 13.91 10.16 1.27 df 110 110 110 110 110 110 P .0053* .8008 .0001* .0002* .1078 .0013*

Variable IAge I-PAR F-PAR PcPAR TT TEI

Mean 12.63 24.32 5.67 72.69 30.14 2.95

*Statistically signicant at P Table II.

Results of independent t test between groups 1 and 2 with comparable initial ages
Group 1 (n 36) (nonextraction) Group 2 (n 58) (maxillary premolar extractions) SD 1.09 7.93 5.80 33.33 9.65 1.52 .05. Mean 13.21 23.91 2.37 88.94 26.72 3.74 SD 1.29 7.18 2.88 14.28 10.53 1.39 df 92 92 92 92 92 92 P .2639 .9151 .0017* .0030* .1700 .0022*

Variable IAge I-PAR F-PAR PcPAR TT TEI

Mean 12.92 24.08 5.27 73.78 29.72 2.78

*Statistically signicant at P

IAges, and the groups were compared again with the t test. Descriptive statistical analysis was used to show the patient distribution according to the F-PAR. The occlusal results obtained for each component of the PAR were individually compared between the groups with the Mann-Whitney U-test. A nonparametric test was used because the values of each PAR component did not have normal distribution, according to the Kolmogorov-Smirnov test.33 To investigate whether 2-phase treatment or delayed extractions had inuenced F-PAR and TT, the following comparisons were made: group 1 and subgroups 2A and 2B were compared with each other with ANOVA, followed by Tukey tests; subgroup 1B was compared with group 2, and subgroups 1A and 2A were compared with t tests.
RESULTS

The I-PAR and F-PAR did not have signicant systematic errors, and the casual errors were within acceptable levels (Dahlberg: I-PAR 0.8062, F-PAR 0.5916). The groups were similar regarding the proportion of Class II Divisions 1 and 2 malocclusion types and sexes ( 2 1.4696 and P .2254; 2 0.4131 and P .5204, respectively). IAge, Pc PAR,

and TEI were statistically greater and the F-PAR was statistically smaller for the extraction group (the smaller the F-PAR score, the greater the occlusal success rate) (Table I). Similar results were obtained when IAge was matched in the groups (Table II). At the posttreatment stage, the extraction group had a greater percentage of patients with PAR scores equal to zero and a smaller PAR range (Table III). When several occlusal characteristics of the F-PAR index were individually compared between the groups, a better AP relationship of the buccal occlusion was observed in the extraction group (Table IV). The immediate-extractions subgroup had a statistically shorter TT and a higher TEI than the delayed-extractions subgroup and the nonextraction group. The F-PAR score and the PcPAR were similar between the immediate and the delayed-extractions subgroups, and statistically greater and smaller in the nonextracion group, respectively (Table V). The 2-phase nonextraction subgroup had a greater F-PAR score, a smaller PcPAR, and a smaller TEI than the extraction group (Table VI). A statistically longer TT and a smaller TEI were found for the 1-phase nonextraction subgroup compared with the immediate-extractions subgroup (Table VII).

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Table III.

Descriptive analysis of the patients percentages in groups 1 and 2 according to F-PAR

0 2 3 4 5 6 7 8 9 10 11 12 14 15 16 18 20

F-PAR (score) Cumulative %, group1 (nonextraction) Cumulative %, group 2 (maxillary premolar extractions) Table IV.

30.2

37.2

41.8

51.1

53.4

62.7

67.4

72

81.3

81.3

86

86

88.3

90.6

95.3

97.6

100

44.9

62.3

65.2

81.1

86.9

89.8

94.2

95.6

95.6

98.5

98.5

100

100

100

100

100

100

Results of the comparison of the F-PAR individual components between groups 1 and 2 (Mann-Whitney
Group 1 (n 43) (nonextraction) Mean rank 64.97 61.86 62.04 57.60 60.30 55.48 Group 2 (n 69) (maxillary premolar extractions) Mean rank 51.21 53.15 53.04 55.81 54.13 57.11 Z 2.180 1.379 1.426 0.284 0.978 0.257 P .0292* .1679 .1536 .7762 .3280 .7969

U test)

Variable AP OVJ OVB ML CB C

OVJ, overjet; OVB, overbite; ML, midline; CB, crossbite; C, crowding. *Statistically signicant at P .05. Table V.

Results of ANOVA and Tukey tests between group 1 and subgroups 2A and 2B
Subgroup 2A (n 47) (maxillary premolar extractions, immediate extractions) Mean 24.34a 2.80b 87.41b 23.60b 3.95b SD 7.47 3.13 14.40 6.31 1.26 Subgroup 2B (n 22) (maxillary premolar extractions, delayed extractions) Mean 23.13a 1.59b 91.99b 34.21a 3.08a SD 7.35 2.08 12.56 12.93 1.28 F 0.223 8.82 7.27 11.37 10.31

Group 1 (n 43) (nonextraction) Variable I-PAR F-PAR PcPAR TT TEI Mean 24.32a 5.67a 72.69a 30.14a 2.69a SD 7.67 5.62 31.38 9.74 1.43

ANOVA P .8002 .0002* .0010* .0000* .0000*

Different letters represent statistically signicant differences. *Statistically signicant for P .05.

DISCUSSION

Our subjects were selected primarily on the basis of a complete bilateral Class II malocclusion, independent of the associated cephalometric skeletal characteristics. Since both groups were similarly chosen, it could be expected that these characteristics would be evenly distributed between them. Usually, it is not the skeletal characteristics of a Class II malocclusion that primarily determine whether it should be treated with or without 2 maxillary premolar extractions but, rather, the patients development stage, because maxillary-premolarextraction treatment has been preferentially used in nongrowing Class II patients.2,14,34-37 Nevertheless, the similarity of the malocclusion types and the initial malocclusion severity points toward cephalometric compatibility of the groups.38 Additionally, the primary objective was to investigate whether there was a dif-

ference in the nal occlusal success rate between these 2 treatment protocols. Further studies on the inuence of skeletal pattern on our results are being conducted. At the beginning of treatment, the groups were similar, except for IAge (Table I). Even though a younger age would favor Class II treatment of the nonextraction group,31,39 the extraction group had more favorable occlusal results (Table I). Nevertheless, to eliminate any concern, the groups were divided into subgroups with matching IAges, which were compared with the t test (Table II). The F-PAR and the PcPAR results had statistically signicant differences between groups 1 and 2, with more favorable results for group 2, as shown in Table I. This demonstrates that Class II malocclusion treatment with extraction of 2 premolars not only allows a better occlusal success rate, but also produces a greater

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Table VI.

Results of independent t test between subgroup 1B and group 2

Subgroup 1B (n 21) (nonextraction, 2-phase) Group 2 (n 69) (maxillary premolar extractions) Mean 23.95 2.42 88.87 26.99 3.67 SD 7.40 2.88 13.91 10.16 1.33 df 88 88 88 88 88 P .1899 .0078* .0144* .0548 .0067*

Variable I-PAR F-PAR PcPAR TT TEI

Mean 26.42 4.95 77.89 31.96 2.74 .05.

SD 7.84 5.75 26.69 10.53 1.42

*Statistically signicant at P Table VII.

Results of independent t test between subgroups 1A and 2A

Subgroup 2A (n 47) (maxillary premolar extractions, immediate extractions) Mean 24.34 2.80 87.41 23.60 3.95 SD 7.47 3.13 14.40 6.31 1.26 df 67 67 67 67 67 P .2917 .0011* .0015* .0121* .0003*

Subgroup 1A (n 22) (nonextraction, 1-phase) Variable I-PAR F-PAR PcPAR TT TEI Mean 22.31 6.36 67.73 28.40 2.65 .05. SD 7.11 5.53 35.19 8.82 1.48

*Statistically signicant at P

proportion of changes in the initial improper dental relationships. Results of the subgroups comparison with matching IAges showed a similar tendency of the groups (Table II). The better occlusal success rate of group 2 is also shown by the greater percentage of patients with a PAR score equal to zero in relation to group 1 at the end of treatment. According to Richmond et al24 and Buchanan et al,40 when the PAR index at the end of treatment is smaller than or equal to 5, the occlusion is considered almost perfect. The extraction group had 86.9% and the non-extraction group had 53.4% of the patients in this correction range (Table III). To determine which PAR components had primarily contributed to the occlusal success rate difference between the groups, they were individually compared. The extraction group had a statistically smaller posttreatment score and, consequently, a greater occlusal success rate of molar and premolar AP relationship correction than group 1. This showed that AP relationship correction was the primary component that contributed to the poorer occlusal results in group 1 (Table IV). This seems logical because nonextraction Class II treatment requires twice as much anchorage reinforcement and consequently more patient compliance to achieve a molar Class I relationship than the 2-maxillarypremolar-extraction protocol to maintain the Class II molar relationship.13 Therefore, these results support the

ndings of other studies that suggest that treatment difculty increases when a full-cusp Class II molar relationship must be completely corrected.2,4-6,8,9,13,14 The following paragraphs theoretically illustrate the greater difculty of the nonextraction approach. Treatment of complete Class II malocclusions with extraction of only 2 maxillary premolars requires anchorage reinforcement to avoid mesial movement of the posterior segment during retraction of the anterior teeth. Because the average mesiodistal diameter of premolars is 7 mm, the anterior teeth should therefore be distalized through this distance.13 Appliances that provide this anchorage reinforcement are primarily extraoral, thus requiring patient compliance for a successful treatment result. In complete Class II therapy without premolar extractions, the need for anchorage reinforcement is even greater, because the posterior segment must be distalized 7 mm to achieve a Class I molar relationship at the end of treatment.41,42 Afterwards, all anterior teeth must be distalized 7 mm (or space units13), corresponding to the distalization of the posterior segment. Therefore, there will be 7 mm of distalization of the posterior segment added to 7 mm of the anterior segment, for a total of 14 mm of distalization for both posterior and anterior segments; this is twice the amount required for Class II correction with extraction

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of only the maxillary premolars.13 Consequently, the need for anchorage reinforcement in those patients is twice as great, and treatment success depends even more on patient compliance. These explanations obviously illustrate only statically the amount of required anchorage and patient compliance for the various situations. Nevertheless, such mechanisms of correction should be associated with growth, which might help in achieving a satisfactory occlusal outcome.30,31,43-46 If the patient is still growing, the probability of success of the mentioned protocols is considerably increased because the extraoral appliances for anchorage reinforcement not only distalize the maxillary teeth, but also redirect maxillary growth, restricting its anterior displacement, which will be valuable for Class II correction. Moreover, mandibular growth, as well as its normal anterior displacement, will increase the probability of correction of the AP discrepancy.31,43,47 This growth potential is even more important in Class II patients who receive nonextraction treatment because, as previously shown, they will require more distalization of the maxillary teeth; this might be reduced by an association with redirection of growth of the apical bases.31,45,47 Therefore, the great limitation of nonextraction Class II treatment in adults and nongrowing patients can be noticed. TT was similar between the 2 groups (Tables I and II). However, because 31.8% of the patients in the extraction group had delayed extractions, which can inuence treatment time, the group was subdivided. The TEI was dened as the ratio between PcPAR and TT (TEI PcPAR/TT), creating a TEI that allowed a true and objective comparison of treatment efciency. The 2-maxillary-premolar-extraction group had a statistically greater TEI than the nonextraction group because the occlusal changes were greater during a similar treatment time period (Tables I and II). When the extraction subgroups of immediate extractions and delayed extractions (subgroups 2A and 2B) were compared with group 1, both subgroups had statistically smaller F-PAR and greater PcPAR values than group 1 (Table V). This suggests that even the patients previously assigned to nonextraction treatment, who had delayed extractions because of decient compliance, complied with the lesser anchorage requirements of the 2-maxillary-premolar-extraction protocol13 and had a better occlusal success rate than the compliant patients of the nonextraction approach. TT in the immediate-extractions subgroup was statistically smaller than in group 1 and similar between the delayed-extractions subgroup and group 1 (Table V). This demonstrates that it was the delayed-extraction patients that accounted for a similar treatment time in

groups 1 and 2 when directly compared. Therefore, when the 2-maxillary-premolar-extraction protocol is immediately undertaken, it has a statistically shorter TT than the nonextraction protocol. These results contradict others that associated the number of extractions with increased TT.3,7,8,10,16,48,49 However, in these studies, the malocclusions were not homogeneous in malocclusion type and severity.7,8,10,16,48,49 Consequently, the shorter TT of the nonextraction patients might reect simpler treatments for localized problems; extractions, in contrast, tend to be strongly associated with the treatment of more marked discrepancies3,7,10,16 (which require more extensive tooth movements). It is reasonable to speculate that treatment of a Class I malocclusion without extractions is faster than that with extractions, since retraction of the anterior teeth demands additional time. Also, it would be expected that nonextraction treatment of Class I malocclusions would have a shorter TT than nonextraction treatment of Class II malocclusions because of the additional time to correct the AP relationship. Therefore, the inuence of the number of extractions on TT requires investigation with similar malocclusion type and severity and with different treatment protocols to assess the actual contribution of the extractions on TT. In this study, with these controlled parameters, it was shown that the immediate-extraction protocol of 2 maxillary premolars had even a statistically shorter TT than the nonextraction approach. As a consequence of a statistically shorter TT of the immediate-extractions subgroup, its treatment efciency was also signicantly greater than the nonextraction group with a higher value than the extraction group. Furthermore, the smaller occlusal success rate (greater F-PAR) of the nonextraction group also accounted for the smaller TEI observed in this group (Table V). Therefore, it can be concluded that the difculty in correcting the Class II molar relationship was the factor that most contributed to the smaller TEI of the nonextraction protocol because the failure to achieve this treatment goal signicantly compromised its TT and F-PAR. The TEI of the delayed-extractions subgroup was similar to the nonextraction group even though it had a greater PcPAR. This was because the TT of this group was longer, although not signicantly in relation to the nonextraction group. The claim that 2-phase Class II malocclusion treatment produces better orthodontic results than those accomplished in only 1 phase nds support in some studies,23,50,51 although several controversies exist about this subject.19,21,52-54 Because, in the nonextraction group in 21 of 43 patients (subgroup 1B), treatment was divided into orthopedic and orthodontic phases, it

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was speculated that this subgroup could have achieved occlusal success similar to that of the extraction group and that the less satisfactory result of the nonextraction group was due to the nonextraction subgroup treated in only 1 phase (subgroup 1A). However, results obtained with the 2-phase nonextraction treatment showed a smaller occlusal result success rate (greater F-PAR) and a smaller PcPAR than the extraction treatment (Table VI). Therefore, these results do not support the hypothesis that 2-phase treatment signicantly inuences Class II treatment results and evidences the difculty of molar relationship correction as the factor that most compromised the nonextraction treatment results.2,4,6,8,9,13,14,55 TT in the 2-phase nonextraction treatment was similar to the extraction group, because the delayedextraction subgroup contributed to prolong TT, as already discussed (Table VI). Reports stating that 2-phase Class II malocclusion treatment increases TT suggest that this treatment protocol would have inuenced TT of the nonextraction group.7,16,17,19,21,53 However, the 1-phase nonextraction subgroup had a signicantly longer TT than the immediate-extractions subgroup (Table VII). Thus, the longer TT of the nonextraction group cannot be attributed to the 2-phase subgroup. Therefore, the greater difculty imposed by the attempt to correct the Class II molar relationship in the nonextraction group was the factor that most contributed to increase TT.2,8,11,16,17 Despite similar TTs, the TEI of the extraction group was statistically greater than that of the 2-phase nonextraction subgroup (Table VI), alike results of the groups comparison (Table II). The compliance necessary for treatment success varies according to patient age and malocclusion severity.4,9,30,31 Compliance, age, and malocclusion severity are clinical variables that cannot be controlled by the operator, because they are inherent to the patient. Because 2-maxillary-premolar-extraction Class II malocclusion treatment reduces by half the compliance required from the patient,13 our ndings show that a greater occlusal success rate and a shorter TT can be expected with this protocol, increasing treatment predictability, even when used in patients with reduced growth potential or severe malocclusions. In spite of this evidence, a certain reluctance persists in the literature for 2-maxillary-premolar-extraction Class II treatment in growing patients, restricting its application to nongrowing patients.2,34-37,56 This approach appears to be a conditioned attitude rather than a decision based on scientic evidence, since orthodontic treatment results during the growth period are predominantly dentoalveolar regardless of orthodontic technique, treatment

protocol, or appliance type.19,57-63 Therefore, there is evidence to justify the 2-maxillary-premolar-extraction protocol during the pubertal growth period because it requires less patient compliance.2,5,6,13,14 Consequently, moderate patient compliance with extraoral headgear or functional appliance can be insufcient to successfully treat by nonextraction a complete Class II malocclusion, but it can be suitable for a 2-maxillarypremolar-extraction protocol.4,9 Because treatment success is an expectation that invariably falls on the orthodontists clinical conduct,64 and noncompliance is not always accepted by the parents or the patient as an excuse for unsatisfactory results or increased TT, the treatment protocol choice should be based, preferably, on treatment efciency.
CONCLUSIONS

According to these results, the null hypothesis was rejected because Class II malocclusion treatment with 2 premolar extractions showed a better occlusal success rate, in a shorter TT, with consequently greater treatment efciency than the nonextraction protocol. The less satisfactory results of the nonextraction Class II treatment were related primarily to the smaller AP relationship correction success, because of the greater patient compliance required with anchorage reinforcing appliances.

REFERENCES 1. Birkeland K, Furevik J, Boe OE, Wisth PJ. Evaluation of treatment and post-treatment changes by the PAR Index. Eur J Orthod 1997;19:279-88. 2. Bryk C, White LW. The geometry of Class II correction with extractions. J Clin Orthod 2001;35:570-9. 3. Chew MT, Sandham A. Effectiveness and duration of two-arch xed appliance treatment. Aust Orthod J 2000;16:98-103. 4. Jacobs T, Sawaengkit P. National Institute of Dental and Craniofacial Research efcacy trials of bionator Class II treatment: a review. Angle Orthod 2002;72:571-5. 5. Janson G, Dainesi EA, Henriques JFC, Freitas MR, Lima KJRS. Class II subdivision treatment success rate with symmetric and asymmetric extraction protocols. Am J Orthod Dentofacial Orthop 2003;124:257-64. 6. 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. 7. OBrien K, 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. 8. Vig KWL, Weyant R, Vayda D, OBrien KD, Bennett E. Orthodontic process and outcome: efcacy studiesstrategies for developing process and outcome measures: a new era in orthodontics. Clin Orthod Res 1998;1:147-55. 9. Wheeler TT, McGorray SP, Dolce C, Taylor MG, King GJ. Effectiveness of early treatment of Class II malocclusion. Am J Orthod Dentofacial Orthop 2002;121:9-17.

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