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MAXILLARY SECOND MOLAR

EXTRACTIONS IN ORTHODONTIC
TREATMENT
This article is a review of the rationales, indications, methods, and
effects of orthodontic treatment with maxillary second molar extractions. In addition to the patients malocclusion, specific considerations about the status and position of the maxillary second and third
molars should be taken into account. In recent years, the development of temporary anchorage devices, in addition to extraoral traction and intraoral distalization appliances, has become another armamentarium in the distalization of the maxillary posterior teeth, which
may affect the selection of teeth to be extracted from second to third
molars. In conclusion, extraction of maxillary second molars is a
viable option in selected cases at present, but it is important to
understand the indications and limitations of this treatment choice.
World J Orthod 2008;9:5261.

Wilson Lee, BDS, BSc, MOrth,

MOrth RCS (Edin)1
Ricky Wing-Kit Wong, BDS,
MOrth, PhD, MOrthRCS,
FRACDS2
Tomio Ikegami, DDS, Cert
Pedo, Cert Orth, MSc,
Dip ABO3
Urban Hgg, DDS, Odont
Dr, FDSRCS (Edin)4

1Advanced

he maxillary second molars are not a

common choice for extraction in orthodontic treatment. The first comprehensive review of the role of maxillary second
molar extractions in orthodontic treatment was published in 1939,1 while the
most recent was published in 1996.2
The purpose of this article is to review
contemporary views about this treatment
option. Previously published reports on
extraction of the second molars were primarily based on the authors personal
clinical experience rather than evidencebased research. 3,4 While most of the
reports referred to cases treated with the
extraction of all 4 second molars,57 only
1 report was about extraction of only the
maxillary second molars.2 The last comprehensive review of the literature on
extraction of second molars in orthodontic treatment was 20 years ago.8

NORMAL DEVELOPMENT OF
MAXILLARY SECOND
MOLARS
On average, the calcification of the maxillary permanent molars commences at
2.5 to 3 years of age. The crown is fully
formed at 7 to 8 years, and the tooth
erupts at 12 to 13 years of age, with its
final root formation at 14 to 16 years.9
According to a study by Ling,10 the average mesiodistal crown diameter of the
maxillary second molar of a 12-year-old
Southern Chinese child is 10.3 mm in
males and 10.0 mm in females. In Caucasians of the same age, it is 10.4 mm in
boys and 9.8 mm in girls.11

Diploma student, Discipline of Orthodontics, Faculty of

Dentistry, The University of Hong
Kong, Hong Kong SAR, China; private practice of orthodontics, Hong
Kong SAR, China.
2Associate Professor, Discipline of
Orthodontics, Faculty of Dentistry,
The University of Hong Kong, Hong
Kong SAR, China.
3Honorary Clinical Associate Professor, Discipline of Orthodontics, Faculty of Dentistry, The University of
Hong Kong, Hong Kong SAR, China;
private practice of orthodontics,
Kumamoto, Japan.
4Chair and Professor, Discipline of
Orthodontics, Faculty of Dentistry,
The University of Hong Kong, Hong
Kong SAR, China.
CORRESPONDENCE
Dr Wilson Lee
Discipline of Orthodontics
Faculty of Dentistry
The University of Hong Kong
2/F, Prince Philip Dental Hospital
34 Hospital Road
Sai Ying Pun
Hong Kong SAR, China

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Table 1 Indications and contraindications of maxillary second molar extraction in

orthodontic treatment
Indications
Class II molar and canine relationship with good facial profile
Deep overbite
Posterior crowding and/or mild anterior crowding
Grossly carious, periodontally involved, or ectopically erupted maxillary second molars
Distally tilted developing maxillary third molars
Contraindications
Excessively protrusive facial profile
Agenesis of permanent teeth
Grossly restored, carious, or periodontally involved maxillary first permanent molars

RATIONALE FOR MAXILLARY

SECOND MOLAR EXTRACTION
The main indication for extraction of
teeth in orthodontic treatment is to create space. Various rationales for the
selection of maxillary second molar
extraction are reviewed in the following
sections and summarized in Table 1.

Orthodontic camouflage of Class

II malocclusion
Extraction of maxillary second molars
was once suggested to be indicated for
the correction of Class II division 1 malocclusion, provided there was excessive
labial inclination of the maxillary incisors
with no spacing and minimal overbite
and the unerupted maxillary third molars
were in good position and of proper
shape.12 The diagnostic space-management guidelines of the Tweed-Merrifield
philosophy indicated this option in cases
of mild skeletal Class II pattern with an
ANB angle between 5 and 8 degrees.13
This extraction option is also suitable for
patients with a skeletal Class II malocclusion, as dentoalveolar compensation, in
those cases for whom bite-jumping is not
recommended because of a prognathic
maxilla and near-correct anterior-posterior positioning of the mandible.2,14,15
Patients with Angle Class II division 2
malocclusions have retroclined maxillary
incisors and deep overbite. If a protrusive

upper lip and prognathic maxilla are also

present, extraction of the maxillary first
premolars will reduce lip protrusion; however, this option increases the danger of
root resorption during space closure, due
to the large amount of root torque
required to move the roots of the maxillary incisors into a more palatal position.16 By extracting the maxillary second
molars, this problem can be avoided
because the orthodontic tooth movement
is slow with simultaneous distalization of
all maxillary teeth, allowing bone remodeling along the maxillary incisor roots to
take place. It also allows more efficient
torque control of the maxillary incisors.17

Facial profile
Extraction of the maxillary second molars
has become a popular treatment option
when there is concern about the potential adverse effect upon the facial profile
with extraction of the maxillary first premolars. Maxillary second molars are
located in the posterior part of the arch;
therefore, the extraction of these teeth
will have less effect on the positioning of
the maxillary incisors during orthodontic
treatments than would extraction of the
maxillary premolars.18 Thus, extraction of
the maxillary second molars is indicated
when a so-called dished-in appearance
of the face at the end of facial growth
should be avoided.15

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Fig 1 Treatment sequence of a female, 12 years 9 months of age, with an Angle Class II division 1 malocclusion. (a) Pretreatment. (b) After 6 months of cervical headgear. (c) After 2 years of headgear treatment. Note that the axial inclination of the
maxillary incisors was corrected as the posterior teeth were distalized. (d) Fixed appliance, worn for 3 months. (e) Finishing
stage with the multiloop edgewise archwire technique. (f) Posttreatment.

Distalization of the buccal segment

Extractions of the maxillar y second
molars and distalization of maxillary posterior teeth may be indicated in patients
with a good facial profile and skeletal
Class I pattern but who have Class II
molar and canine relationships, moderate maxillary arch crowding, and mild
mandibular arch crowding.19 This is particularly true in patients with retroclined
maxillary and mandibular incisors. The
extraction of the maxillary second molars
provides the space required for alignment of the teeth and for attaining correct occlusal relationships, as well as
facilitating the distal movement of the
maxillary posterior teeth.
In cases of severe posterior crowding
in the maxillary arch, extraction of the
maxillary second molars may also be
indicated. In some complex cases, it may
become necessary to extract the maxillary first premolars, as well.

If the developing maxillar y third

molars encounter a lack of space for
eruption, the space created after extraction of the maxillary second molars can
provide space not only for the distalization of the posterior teeth, but also for
the eruption of the maxillary third molars.
Research has shown that, in general, the
maxillary third molars will erupt favorably
in such cases.20 Simple extraction of the
maxillary second molars may prevent
possible trauma arising from the surgical
removal of eventually impacted maxillary
third molars.
A sample case is presented in Figs 1
to 3 to demonstrate the successful management of severe Angle Class II division
1 malocclusion, with extraction of maxillary second molars combined with headgear treatment and fixed appliances.

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Fig 2

Lateral profiles, frontal profiles, and overjet: (a to c) Pretreatment. (d to f) Posttreatment. (g to i) Ten years posttreatment.

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Fig 3 Panoramic radiographs. (a) Pretreatment. (b) Nine months after headgear treatment. (c) Sixteen months after headgear
treatment. (d) Three years after the start of headgear treatment. (e) Posttreatment. Note the positioning of the maxillary third
molars. (f) Retention (3 years 9 months posttreatment).

Condition of the maxillary second

molars
When the maxillary second molars are
grossly carious, periodontally compromised, or ectopically erupted, 21 their
extraction can also be considered as a
treatment option.

CONTRAINDICATIONS
Agenesis, or severe mesioangulation, of
the maxillary third molars is a contraindication of orthodontic treatment with
extraction of the maxillary second molars
(see Table 1). The general pattern of maxillary third molar eruption is downward

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and forward21; an ideal maxillary third

molar will have a slight distoangular position that will allow it to rotate mesially as
it descends into the occlusion.
Orthodontic treatment with maxillary
second molar extraction requires distalization of the maxillary first molars, which
may result in some bite opening; therefore, it may be contraindicated in patients
with open bite. Patients with a maxillary
protrusive facial profile would likely benefit more from extraction of the maxillary
first premolars, since conventional distalization would eventually result in posterior
rotation of the mandible, thus increasing
the lower facial height and worsening the
facial appearance. The use of the new
temporary anchorage devices (TADs)
seems to have the potential to reduce
these adverse effects by providing vertical
control.

ADVANTAGES
From the literature, the following reasons
are proposed as the major advantages of
maxillary second molar removal: (1) no
excessive retrusion of the maxillary anterior teeth and normalization of maxillary
incisor inclination during retraction, compared to maxillary first premolar extraction, and hence less adverse change of
profile in cases of mild Class II malocclusion with mild crowding22; (2) better stability of treatment results23,24; (3) avoidance of maxillary molar staggering and
impaction22; (4) facilitation of maxillary
first molar distal movement15; (5) distal
movement of the maxillary dentition only,
as needed to correct the overjet and maxillary crowding; (6) no trauma of maxillary
third molar extraction22; and (7) preservation of more the patients complete
dentition, from right molars to lef t
molars, compared with extraction of all
first premolars.
It has been demonstrated that the
extraction of maxillary second permanent
molars can be effective in many cases
where removal of maxillary first or second premolars would other wise be
recommended.25

DISADVANTAGES
The following are disadvantages of the
maxillary molar extraction treatment
option: (1) too much tooth substance
removed in Class I malocclusions with
mild crowding 15,24; (2) extraction sites
are far from the area of concern in moderate-to-severe anterior crowding15; (3)
extraction sites are of no help in the correction of anteroposterior discrepancies
without patient cooperation in wearing
extraoral appliances capable of moving
the dentition en masse distally; (4)
potentially insufficient size and form of
these molars 24; and (5) unpredictable
path of eruption of maxillar y third
molar.26

OPTIMAL TIMING
FOR EXTRACTIONS
Ideally, maxillary second molars should
be extracted when the maxillary third
molars reach the vertical midline of the
maxillary second molar root in a Class I
malocclusion.27 In a Class II malocclusion, because treatment often needs distalization of the maxillary first molars, the
maxillary third molars should be approximately at the level of the cementoenamel
junction of the maxillary second molars
at the time of extraction.27 The maxillary
third molars should be developed to their
bifurcation before extraction of the maxillary second molars.9

CHANGES IN MAXILLARY
THIRD MOLAR POSITION
With proper diagnosis and careful treatment planning, most maxillary third
molars would erupt successfully into
good position.25,27 After extraction of the
maxillary second molars, the maxillary
third molars rotate and tip mesially with
descent; the greater the original distal
angulation, the greater the amount of
rotation.20
Recent research has shown that maxillary third molars uprighted and acceptably replaced maxillary second molars
after extraction for orthodontic purposes
57

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in 95% of such-treated cases.27 Unsuccessful eruption of the maxillary third

molars has been shown to be due to
prior excessive mesial tilting or lack of
proximal contact.27
The eruption prognosis of the maxillary third molars improves when they
have a favorable inclination, with a 15- to
30-degree angle distal to the long axis of
the maxillary first molars.21,23 The mesial
surface of the unerupted maxillary third
molars should be fairly in line horizontally
with the distal surface of the mandibular
second molars.21
With proper selection of cases, the
form and size of the erupted maxillary
third molars after orthodontic treatment
with extraction of the maxillary second
molars was acceptable nearly 90% of the
time; all maxillary third molars erupted
with mesial contact, and in 90% of the
cases, the maxillary third molars had
acceptable axial inclination and position
without the need for further alignment.2
Bennett and McLaughlin28 concluded
that the pantomographic evaluation of
the changes in third-molar angulation
before and after orthodontic treatment
with extraction of all second molars were
not statistically different. In both groups,
the maxillary third molars showed an
improvement in angulation, while the
mandibular third molars showed an
undesirable increase in angulation. A
recent study by De-la-Rosa-Gay et al 27
reported similar results.

EFFECTS OF ORTHODONTIC
TREATMENT WITH
EXTRACTION
Few studies have investigated the effects
of extraction of maxillary second molars
in orthodontic treatment. These studies
had different treatment objectives and
the characteristics of the samples were
different.2,6,29
One of the objectives of extracting
maxillary second molars is to minimize
the change in patient profile after orthodontic treatment. Basdra et al2 did a preand posttreatment cephalometric analysis of 32 young patients (mean age of
14.6 years) with Class II malocclusion

who had extraction of maxillary second

molars. Primarily angular measurements
were used in the cephalometric analysis;
however, the linear measurements
showed that both upper lips and maxillary incisors were significantly retracted.
This study did not include any control
group.
Staggers6 examined treatment results
of maxillary and mandibular second
molar extraction cases and compared
them with treatment results of maxillary
and mandibular first premolar extraction
cases. The results showed that the 2
groups had fewer differences than often
indicated by advocates of second molar
extraction. However, the maxillary and
mandibular incisors and the lower lip in
the premolar extraction group were
retracted significantly more than those in
the maxillary second molar group. The
resulting facial profile after extraction of
second molars appears to have no significant difference from that obtained after
extraction of first premolars. However,
this comparison would only be valid if the
amount and site of crowding were similar
in both groups, factors that were not
mentioned in the study.28 The average
treatment time did not differ statistically
between the groups.
Waters and Harris29 conducted a retrospective cephalometric study to compare
the nature of the skeletodental correction
of maxillary second molar extraction and
nonextraction treatments in correcting
Class II malocclusions. The sample comprised Class II, deep-bite, low-angle adolescents; half were treated with maxillary
second molar extraction and half were
treated without extraction. Pitchfork
analysis30,31 was used to evaluate sagittal changes (in mm) of the teeth and supporting bones, relative to the functional
occlusal plane. There was no significant
difference in the dentofacial morphology
between the 2 groups at the start of
treatment. Several skeletodental treatment changes differed significantly
between the 2 groups. The maxillary second molar extraction group exhibited distal movement of the maxillar y first
molars (1.2 mm vs 0.0 mm), and there
was greater flaring of the mandibular
incisors in the nonextraction group (9.1

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degrees vs 3.5 degrees). The maxillary

incisor roots were torqued lingually in
both groups, but there was more anterior
crown movement in the nonextraction
group (2.0 mm vs 0.0 mm). Sagittal
molar correction in the maxillary second
molar group was a result of distalizing of
the maxillary first molars to correct the
malocclusion in the nonextraction group.
On average, the extraction group finished
active treatment 7 months earlier than
the nonextraction group. It was concluded that in properly selected Class II
malocclusions, extraction of maxillary
second molars is a viable alternative
treatment choice.

EXTRACTION IN CONJUNCTION
WITH FIXED APPLIANCE
THERAPY
Rix 32,33 showed that sometimes the
extractions of 4 premolars provided more
space than was actually needed in Class
II division 1 malocclusions with borderline
crowding of the mandibular incisors. As a
result, he recommended the extraction of
4 second molars in conjunction with
monobloc therapy as a better alternative.
In a study on extraction of maxillary
and mandibular second molars in 78
patients with Class II malocclusions, 21
patients had no orthodontic treatment, 9
patients were treated with activators with
springs to move the first molars distally,
and 48 had fixed appliances. 34 It was
stated that the advantages of this
method of treatment included ease in
distally moving mandibular first molars if
they were mesially tipped, the rapid and
complete eruption of the third molars,
and complete space closure of the
extraction sites. The limitation of this
approach is the assumption of the presence and proper eruption of the third
molars. Moreover, moving mandibular
first molars distally can be mechanically
difficult and, in Class II cases, there is
the need to move all the anterior and
posterior permanent teeth distally for the
correction of overjet.
Sfondrini et al35 did a comprehensive
analysis of the effect of maxillary molar
distalization with various appliances.

They mentioned that distalization of maxillary posterior teeth with the extraction
of maxillary second molars will reduce
the treatment duration compared to
nonextraction treatment. Various types of
distalization appliances were discussed,
including headgears, acrylic cervical
occipital, transpalatal arch, Wilson bimetric distalizer, Herbst, Jasper jumper, and
pendulum. It was concluded that if
patient compliance was good and
anchorage demand was maximum, the
use of extraoral traction for distalization
of the maxillary first molars was the best
treatment option. However, the use of
TADs for maxillary distalization of molars
was not mentioned.
At present, there are no scientifically
viable data available to compare the
long-term results of similar malocclusions
corrected with maxillary premolar vs
maxillary second molar extractions.

EXTRACTION IN CONJUNCTION
WITH TADS
Temporar y anchorage devices have
become increasingly popular in orthodontic treatment. There have been recent
studies discussing the effects of TADs in
distalization of maxillary posterior teeth
with or without the extraction of maxillary
second or third molars.3640 A study by
Sugawara et al38 reported that the average amount of distalization of the maxillary first molars was 3.8 mm at the crown
level and 3.2 mm at the root level. Kyung
et al39 reported the use of a midpalatal
microscrew together with a transpalatal
arch to distalize the maxillar y first
molars, illustrated with 2 case reports. In
these 2 young patients, the maxillary
molars moved distally 5 mm from the
crowns and 3.5 mm from the apices
within 3 to 5 months, without the extraction of second molars.
Gelgor et al41 investigated the efficiency
of intraosseous screws for anchorage in
maxillary molar distalization and the sagittal and vertical skeletal, dental, and soft
tissue changes after maxillary molar distalization using intraosseous screw-supported anchorage. An anchorage unit was
prepared for molar distalization by placing
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Table 2 Summary of effects expected after maxillary second molar extraction

in orthodontic treatment
Effect
Extraoral
Vertical
Dental
Transverse

Increase in upper liptoE-line; more palatal root torque but less anterior crown movement
than in nonextraction group
No reported change in vertical relationship
Ninety-six percent of maxillary third molars will erupt into good position
No change

an intraosseous screw behind the incisive

canal at a safe distance from the midpalatal suture, following the palatal
anatomy. The screws were placed and
immediately loaded to distalize the maxillary first molars; the maxillary second
molars were present. The average distalization time to achieve an overcorrected
Class I molar relationship was 4.6
months. The skeletal and dental changes
were measured on cephalograms and
dental casts obtained before and after
the distalization. Analysis of the lateral
cephalograms showed that, on average,
the maxillary first molars were tipped 8.8
degrees and moved 3.9 mm distally. Measurements of the dental casts showed
a mean distalization of 5.0 mm. The maxillary first molars were rotated distopalatally. On average, mild protrusion
(mean 0.5 mm) of the maxillary central
incisors was also recorded. However,
there was no change in overjet, overbite,
or mandibular plane angle measurements. It was concluded that the immediately loaded intraosseous screw-supported anchorage unit was successful in
achieving sufficient maxillary molar distalization without major anchorage loss.

CONCLUSIONS
This review discussed a number of issues
related to maxillary second molar extractions, including the indications, contraindications, advantages, disadvantages, optimal timing for extraction, as
well as how it affects the eruption of maxillary third molars. The reviewed literature
strongly suggests that in carefully
selected cases, the extraction of maxillary
second molars relieves crowding in the

posterior part of the arch and facilitates

eruption of maxillary third molars (Table 2).
It is important to consider the biological and mechanical requirements and
consequences of a particular treatment
plan for both short- and long-term results,
as well as the effects of these decisions
on the duration of treatment, facial profile, periodontal tissues, and functional
occlusion. To determine the possible
advantages of maxillary second molar
extraction versus other extraction and
nonextraction concepts, there is a need
for randomized clinical trials that evaluate and compare both short- and longterm treatment outcomes.

REFERENCES
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