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Relationship between malocclusion severity and treatment success rate in Class II nonextraction therapy
Guilherme Janson,a Fabrcio Pinelli Valarelli,b Rodrigo Hermont Cancado,b Marcos Roberto de Freitas,a and Arnaldo Pinzanc Bauru, Brazil Introduction: The purpose of this study was to evaluate the treatment success rate of Class II malocclusion without extractions, according to initial severity. Methods: Class II subjects (n 5 276) were divided into 2 groups according to the severity of the malocclusion. Group 1 comprised 144 patients with bilateral half Class II malocclusion at the initial mean age of 12.27 years. Group 2 comprised 132 patients who initially had bilateral complete Class II malocclusion at the initial mean age of 12.32 years. The patients initial and nal study models were evaluated with Graingers treatment priority index. Chi-square tests were used to test for differences between the 2 groups for categorical variables. Variables regarding occlusal results were compared with independent t tests. Results: Group 1 had a signicantly better nal occlusal result, a shorter treatment time, and a higher treatment efciency index. Conclusions: Based on these results, it was concluded that bilateral half Class II malocclusion has a better treatment success rate than bilateral complete Class II malocclusion when treatment is conducted without extractions. (Am J Orthod Dentofacial Orthop 2009;135:274.e1-274.e8)

nvestigations have traditionally been concerned with the effects of orthodontic treatment, rather than with the severity of malocclusions or the efciency of treatment methods.1 This is especially true for treatment of Class II malocclusion in which several treatment methods have been described,2-9 yet their efciencies have not been comparatively evaluated. Efciency is the capacity of producing the best results in the least time.10 Theoretically, the greater the Class II anteroposterior discrepancy severity and the older the patient, the smaller the probability of nonextraction correction of the malocclusion.11-13 However, no study has demonstrated the efciency of the nonextraction approach according to the patients Class II anteroposterior severity and age.11 In this study, we aimed to evaluate the treatment success rate of the nonextraction

approach to Class II malocclusions, according to the initial anteroposterior discrepancy severity.

MATERIAL AND METHODS

From the Department of Orthodontics, Bauru Dental School, University of Sao Paulo, Bauru, Brazil. a Professor. b Graduate student. c Associate professor. Based on research by Fabricio Pinelli Valarelli in partial fulllment of the requirements for the PhD degree in orthodontics. Reprint requests to: Guilherme Janson, Department of Orthodontics, Bauru Dental School, University of Sao Paulo, Alameda Octavio Pinheiro Brisolla 9-75, Bauru, SP, 17012-901, Brazil; e-mail, jansong@travelnet.com.br. Submitted, May 2008; revised and accepted, September 2008. 0889-5406/$36.00 Copyright 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2008.09.021

The sample, retrospectively obtained from 4000 documented treated patients from the Department of Or thodontics at Bauru Dental School, University of Sao Paulo, Brazil, consisted of initial (T1) and nal (T2) dental study models of 276 Class II malocclusion patients divided into 2 groups according to anteroposterior discrepancy severity. Group 1 comprised 144 patients (66 boys, 78 girls) with bilateral half Class II malocclusion (molar relationship) at an initial mean age of 12.27 years (SD, 1.49; range, 8.58-16.66 years).14-16 According to their dental stages, 60 patients were in the mixed dentition and 84 in the permanent dentition at T1. All patients in this group nished treatment with the original nonextraction protocol. Group 2 comprised 132 patients (62 boys, 70 girls) who initially had bilateral complete Class II malocclusion (molar relationship) at an initial mean age of 12.32 years (SD, 1.50; range, 7.91-17.25 years).14-16 According to their dental stages, 62 patients were in the mixed dentition and 70 in the permanent dentition at T1. This group had to be subdivided into subgroups 2A and 2B according to having or not completed the original nonextraction treatment plan. This had to be done to include all patients who began
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treatment with a nonextraction approach. Subgroup 2A comprised 107 patients (49 boys, 58 girls) at an initial mean age of 12.24 years (SD, 1.45; range, 7.91-16.33 years) who nished treatment with the original nonextraction protocol. According to their dental stages, 56 patients were in the mixed dentition and 51 in the permanent dentition at T1. Subgroup 2B comprised 25 patients (13 boys, 12 girls) who were reevaluated and had changes in their initial treatment plans, requiring 2 maxillary premolar extractions; nonextraction treatment was unsuccessful due to poor patient compliance. In this way, more reliable and consistent results could be obtained regarding the percentages of patients successfully treated without changes in initial treatment plans. The patients in this group had an initial mean age of 12.65 years (SD, 1.66; range, 9.42-17.25 years). According to their dental stages, 6 patients were in the mixed dentition and 19 in the permanent dentition at T1. Two hundred thirty-one patients had Class II Division 1 malocclusions (121 in group 1, 92 in subgroup 2A, and 18 in subgroup 2B), and 45 had Class II Division 2 malocclusions (23 in group 1, 15 in subgroup 2A, and 7 in subgroup 2B). The additional selection criterion was the presence of all permanent teeth up to the second molars at T2. Molar relationships were assessed on the models, by using the location of the mesiobuccal cusp of the maxillary rst molar and the mesial buccal groove of the mandibular rst molar as reference points. Sample selection was based exclusively on the anteroposterior dental relationship at T1, regardless of any other dentoalveolar or skeletal characteristic. Regarding the initial treatment planning, all patients should have been treated without extractions or at least were originally planned to be treated without extractions. Additionally, the patients selected for the study had to have both T1 and T2 dental study models in good condition and clinical records that described sex, age at T1, and treatment time. The mechanics used with the xed edgewise appliances in both groups were characterized by 0.022 3 0.028-in brackets, associated with extraoral headgear to distalize the maxillary teeth or restrict maxillary forward displacement. Class II elastics were also used when applicable, to aid in correcting the Class II anteroposterior relationship. The usual wire sequence was 0.015-in Twist-Flex or 0.016 Nitinol wire, followed by 0.016-, 0.018-, and 0.020-in, and nally a 0.021 3 0.025 or an 0.018 3 0.025-in stainless steel archwire (all from 3M Unitek, Monrovia, Calif). Deep overbites were usually corrected by reversed and accentuated curve of Spee. The treatment priority index (TPI)17 was calculated on the T1 and T2 study models of each patient, accord-

ing to Table I. The TPI provides weighted subscores for overjet, vertical overbite or open bite, tooth displacement, and posterior crossbites, as well as summary scores reecting the overall severity of the malocclusion. With the exception of rotation and displacement, all TPI components are measured along a continuous scale from positive to negative values. Thus, mandibular overjet and open bite are entered as negative overjet and negative overbite, respectively. A constant corresponding to the molar occlusion is added to the TPI score. Total scores on the TPI range from 0 to 10 or more, with higher scores representing more severe malocclusions.18-20 The TPI components are dened as follows (Fig).18,19 1. Overjet: the anterior distance from the most mesial part of the labial surface of the maxillary central incisor to the labial surface of the opposing mandibular incisor, measured perpendicularly to the coronal plane. Overbite or open bite: with the dental models in centric (convenience) occlusion, the amount of vertical overlap of the maxillary central incisor over the mandibular central incisor taken as a ratio of the total crown height (cervix to incisal edge) of the mandibular incisor. Tooth displacement: the sum of the number of teeth noticeably rotated or displaced from ideal alignment, plus 2 times the number of teeth rotated more than 45 or displaced more than 2 mm. First molar relationship: a constant comprising the severity of the malocclusion, based on the relationships between the maxillary and mandibular rst molars. Posterior crossbites: measures buccolingual deviation in occlusion of postcanine teeth. The measurement is positive for buccal crossbite (rst molar positioned too far buccally) and negative for lingual crossbite. Crossbite is also scored as the number of teeth deviating from ideal cusp-to-fossa t by a cusp-to-cusp relationship or worse.18,19

2.

3.

4.

5.

Two copies of the Figure were required to calculate each patients TPI. On the rst, the achieved value corresponded to the initial severity of the malocclusion, whereas the second showed the nal occlusal status after orthodontic treatment. The improvement as a result of orthodontic treatment was assessed by 2 methods. The rst used the TPI change: the difference between the T1 and T2 scores. The second was the percentage of TPI reduction, which reects the TPI change relative to the T1 score and is calculated by dividing the difference between the T1 and T2 TPI values by the initial

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Table I.

Baseline characteristics and results of the intergroup comparisons (ANOVA and chi-square tests)
Group 1 (half Class II) (n 5 144) Group 2 (complete Class II) (n 5 132) 12.32A (1.50) 8.86B (1.42) 62 70 110 22 62 70 Subgroup 2A (n 5107) 12.24A (1.45) 9.00B (1.48) 49 58 92 15 56 51 P 0.9169 0.0000,* 0.9771

Initial age (y), mean (SD) Initial TPI, mean (SD) Sex Male Female Type of Class II Division 1 Division 2 Dental stage Mixed dentition Permanent dentition

12.27A (1.49) 7.88A (2.23) 66 78 121 23 60 84

0.8479

0.2430

Different letters represent statistically signicant differences in post-hoc comparisons (Tukey HSD test). *Statistically signicant at P \0.05.; ANOVA; chi-square test.

TPI score. Additionally, treatment efciency was assessed. This was dened as the change in occlusal characteristics, evaluated with the TPI, in a period of time and calculated by dividing the percentage of TPI reduction by treatment time.21 This ratio provided the treatment efciency index (TEI). Additionally, successful treatment was dened as a nal TPI score less than 2 points.17 Sixty pairs of dental study models were randomly selected and remeasured by the same examiner (F.P.V.) after a 1-month interval. The casual error was calculated according to Dahlbergs formula,22 S2 5 Sd2/2n, where S2 is the error variance and d is the difference between the 2 determinations of the same variable. The systematic errors were estimated with dependent t tests at P \0.05.23
Statistical analysis

regarded as signicant at P \0.05. These analyses were performed with Statistica software (Statistica for Windows, version 6.0, Statsoft, Tulsa, Okla).
RESULTS

Means and standard deviations for each variable were calculated to enable characterization of the groups. Normal distributions were veried by the KolmogorovSmirnov test (for T1 and T2 TPI scores, TPI change, percentage of TPI reduction, and TEI). Results of this test showed that all variables were normally distributed. Therefore, analysis of variance (ANOVA) was used for comparison between the groups for initial age and severity of malocclusion at T1 (initial TPI). Chi-square tests were used to evaluate compatibility between groups regarding sex distribution, type of Class II malocclusion, and dental stage of the patients, and also to compare the percentages of patients who were successfully treated (nal TPI \2) in both groups. The t test was used to compare nal TPI scores, TPI change, percentage of TPI reduction, treatment time, and the TEI between group 1 and subgroup 2A. Results were

No variable had a systematic error, and the range of casual errors varied from 0.43 (nal TPI) to 0.85 (initial TPI). Group 1, group 2, and subgroup 2A were initially similar according to age, sex, type of Class II malocclusion, and dental stage distribution. The initial TPI score was signicantly smaller in group 1 than in group 2 and subgroup 2A (Table I). The percentage of patients successfully treated (nal TPI \2) was signicantly greater in group 1 compared with group 2 (Table II). Even when the patients of subgroup 2B (reevaluated and with 2 maxillary premolars extracted) were excluded from the comparison, the percentage of group 1 patients successfully treated was still signicantly greater compared with subgroup 2A (Table III). The results of the comparison between group 1 and subgroup 2A showed that group 1 had a signicantly smaller nal TPI, a shorter treatment time, and a greater treatment efciency index (Table IV).
DISCUSSION

The groups were compatible regarding initial age, sex, type of Class II malocclusion, and dental stage distribution, therefore eliminating any inuence of these variables in the results24,25 (Table I). However, group 2 and subgroup 2A (complete Class II) were characterized by greater malocclusion severity at T1; this was expected because the TPI highly depends on the molar anteroposterior relationship. The greater the

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Fig. Treatment priority index (TPI) data collection form.

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Table II.

Comparison of treatment success rate between groups 1 and 2 (chi-square test)

Group 1 (n 5 144) (half Class II) Patients % 79.17 Group 2 (2A 1 2B) (n 5 132) (complete Class II) Patients 67 % 50.37 P 0.0000*

Final TPI \2

114

*Statistically signicant at P \0.05.

Table III.

Comparison of treatment success rate between group 1 and subgroup 2A (chi-square test)
Group 1 (n 5 144) (half Class II) Patients % 79.17 Subgroup 2A (n 5 107) (complete Class II) Patients 67 % 62.61 P 0.0042*

Final TPI \2

114

*Statistically signicant at P \0.05.

Table IV.

Comparison between group 1 and subgroup 2A (independent t test)

Group 1 (n 5 144) (half Class II) Subgroup 2A (n 5 107) (complete Class II) SD 1.09 2.61 16.91 9.92 1.41 Mean 1.83 7.16 79.56 31.20 2.92 SD 1.77 2.13 19.98 11.05 1.44 P 0.0010* 0.0927 0.2066 0.0000* 0.0000*

Variable Final TPI TPI change TPI reduction (%) Treatment time (mo) TEI *Statistically signicant at P \0.05.

Mean 1.23 6.64 82.52 25.06 3.70

anteroposterior discrepancy, the higher the score. Thus, molar relationship is extremely important in the nal malocclusion severity score. There might be some criticism for using Graingers TPI17 for evaluation of the T1 and T2 occlusal statuses instead of the more recent and currently more used peer assessment rating (PAR) index.26-30 The reason for this was that the PAR has some limitations in evaluating the posterior segment anteroposterior relationship, as pointed out earlier.31-33 To overcome this deciency, it was suggested that there should be a different PAR index to separately evaluate Class I, Class II, and Class III malocclusions.34 In this study, an efcient index to evaluate the posterior segment anteroposterior discrepancy was crucial because this is where the major differences are in the nal TPI (treatment success rate) between these Class II malocclusions with distinct severities.11,35,36,37 Group 1 had a higher percentage of treatment success, demonstrating that the greater the malocclusion severity, the less satisfactory the nal occlusal result,

as previously suggested16 (Table II). In this comparison, group 2 included patients originally planned to be treated without extractions; that later changed to treatment with 2 maxillary premolar extractions because of poor compliance. Obviously, these patients were considered to have failed. For this reason, it might be argued that these patients should have not been included because they could have biased the results. Therefore, another comparison was made without these patients, but the results still demonstrated that group 1 had a better occlusal success rate than subgroup 2A; this conrms the assumption that greater Class II anteroposterior malocclusion severity at T1 is related to less satisfactory occlusal outcomes at T216,38 (Table III). Changing 25 patients of 132 in group 2 to the 2 maxillary premolar extraction protocol suggests that only good compliers remained in subgroup 2A. Therefore, if patient compliance had been matched in the groups, it could be speculated that the actual difference in treatment success rates between group 1 and subgroup 2A would be even greater than observed.

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Because of the greater occlusal success rate, group 1 (half Class II) also had a smaller nal TPI than did subgroup 2A (complete Class II) (Table IV). However, the amount of TPI change and the percentage of TPI reduction were not different between the groups. This was because the malocclusion severity of subgroup 2A was originally greater than in group 1. Treatment in both groups provided a similar amount of occlusal changes, but these changes did not have a similar occlusal success rate because the severity of subgroup 2A was greater than that of group 1. Treatment time was longer for subgroup 2A (complete Class II malocclusion) (Table IV). These ndings show that correction of malocclusion needs a shorter treatment time in patients with less severe Class II anteroposterior discrepancies.35,36,39-42 As previously mentioned, the longer treatment time required for the group with complete Class II malocclusion was related to the need to correct the posterior segment anteroposterior relationship.24,35,36,39,42-44 Additionally, orthodontic treatment time was compared between group 1 and subgroup 2A, excluding patients with complete Class II malocclusions who had their treatment plan changed to 2 maxillary premolar extractions. If they were included, treatment time of group 2 would be even longer, because of the time spent in trying to correct the malocclusion without extractions, added to the treatment time with 2 maxillary premolar extractions, increasing the difference in treatment time between these groups. Studies concerned with the variables that can inuence treatment time suggest that it might increase if patients miss their appointments or break the appliances.39-41 There is no evidence of a difference between patients with complete or half Class II malocclusions regarding these variables; thus, they can be considered compatible.43,45 Because both groups had similar TPI changes and percentages of TPI reduction, but group 1 had a shorter treatment time, the TEI of group 1 was signicantly greater than that of subgroup 2A (Table IV). This result is obvious because it is evident that a Class II malocclusion patient with half the anteroposterior discrepancy of another, treated with similar protocols, would need less treatment time for correction and consequently would have greater treatment efciency.11,35,36 However, although theoretically understandable, this had not been scientically shown. These results are related to the greater need of patient compliance in using the extraoral headgear because nonextraction treatment of Class II malocclusion requires correction of molar relationship, and several orthodontic devices for correction of Class II malocclusion are removable and therefore depend on com-

pliance.6 Consequently, the greater the molar anteroposterior discrepancy, the greater the difculty for malocclusion correction and the less effective the orthodontic treatment.35,36,42,44,46,47
Clinical implications

These results suggest that special consideration is needed for the initial occlusal anteroposterior malocclusion severity when planning treatment in Class II patients concerning occlusal success rate and treatment efciency at the evaluated age span. Many treatment protocols might be effective but not efcient. When planning nonextraction treatment for patients with Class II malocclusions, the initial anteroposterior discrepancy plays a great role in the occlusal success rate and treatment efciency. The greater the Class II anteroposterior discrepancy, the smaller the success rate and the treatment efciency with the nonextraction protocols investigated. Therefore, it would be preferable to plan nonextraction treatment when the anteroposterior discrepancy is small. As it increases, occlusal success rate and treatment efciency will be less. This does not mean that a complete Class II malocclusion cannot be treated nonextraction. Treatment can be started without extractions, and, if there is not enough patient compliance, it can be changed to 2 maxillary premolar extraction treatment. However, one should not wait too long to change the treatment plan. If the patient does not comply within 3 months, the 2 maxillary premolar extraction protocol should be started.16,38 If a patient does not signicantly comply during the rst months of treatment, when compliance is highest, he or she will hardly comply later.48 These considerations apply to the age span that we evaluated and to treatment with removable appliances, especially extraoral headgear as was used here, to correct Class II anteroposterior discrepancy. Better response to nonextraction treatment can be observed in younger patients.13,49,50 It can be argued that these comments do not apply to xed intraoral distalizers and xed functional appliances. Concerning xed intraoral distalizers, the mean treatment times reported were 31.651 and 3152 months for small anteroposterior discrepancies; this is longer than the treatment time of group 1. Reports of treatment time for complete Class II malocclusion correction with intraoral distalizers are not available. Therefore, these results might be extrapolated for these appliances also. With regard to xed functional appliances, the mean time reported to correct complete Class II anteroposterior discrepancies is 6 to 9 months, which is satisfactory.53,54 However, after Class II anteroposterior correction, patients are usually

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instructed to use a removable functional appliance as an active retainer for additional 12 months.3 This demonstrates that, even with this treatment approach, some patient compliance is necessary in handling treatment, and the results could be similar to our investigation. However, a specic comparison with complete Class II patients treated with xed functional appliances would help to clarify these issues.
CONCLUSIONS

13.

14.

15. 16.

1.

2.

3.

Bilateral half Class II malocclusion had a statistically greater occlusal success rate than bilateral complete Class II malocclusion when treated without extractions. Nonextraction treatment time was signicantly greater in patients with complete Class II malocclusion when compared with patients with half Class II malocclusion. Nonextraction TEI is signicantly greater in patients with half Class II malocclusion than with complete Class II malocclusion.

17. 18. 19. 20.

21.

22. 23. 24.

REFERENCES 1. Vig PS, Weintraub JA, Brown C, Kowalski CJ. The duration of orthodontic treatment with and without extractions: a pilot study of ve selected practices. Am J Orthod Dentofacial Orthop 1990;97: 45-51. 2. Wieslander L. Long-term effect of treatment with the headgearHerbst appliance in the early mixed dentition. Stability or relapse? Am J Orthod Dentofacial Orthop 1993;104:319-29. 3. Pancherz H. The nature of Class II relapse after Herbst appliance treatment: a cephalometric long-term investigation. Am J Orthod Dentofacial Orthop 1991;100:220-33. 4. Lagerstrom LO, Nielsen IL, Lee R, Isaacson RJ. Dental and skeletal contributions to occlusal correction in patients treated with the high-pull headgear-activator combination. Am J Orthod Dentofacial Orthop 1990;97:495-504. 5. Boecler PR, Riolo ML, Keeling SD, TenHave TR. Skeletal changes associated with extraoral appliance therapy: an evaluation of 200 consecutively treated cases. Angle Orthod 1989;59: 263-70. 6. Bishara SE, Ziaja RR. Functional appliances: a review. Am J Orthod Dentofacial Orthop 1989;95:250-8. 7. Levin RI. Activator headgear therapy. Am J Orthod 1985;87: 91-109. 8. Howe RP. Updating the bonded Herbst appliance. J Clin Orthod 1983;17:122-4. 9. Frankel R. The treatment of Class II, Division 1 malocclusion with functional correctors. Am J Orthod 1969;55:265-75. 10. Hornby AS. Oxford advanced learners dictionary of current English. 4th ed. Oxford, United Kingdom: Oxford University Press; 1993. 11. Janson G, Brambilla AC, Henriques JF, de 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. 12. Tulloch JF, Phillips C, Koch G, Proft WR. The effect of early intervention on skeletal pattern in Class II malocclusion: a random-

25.

26. 27.

28.

29.

30.

31. 32.

33.

ized clinical trial. Am J Orthod Dentofacial Orthop 1997;111: 391-400. Harris EF, Dyer GS, Vaden JL. Age effects on orthodontic treatment: skeletodental assessments from the Johnston analysis. Am J Orthod Dentofacial Orthop 1991;100:531-6. Andrews LF. The straight wire appliance, Syllabus of philosophy and techniques. 2nd ed. San Diego, Calif: Larry F. Andrews Foundation of Orthodontic Education and Research; 1975. Creekmore TD. Where teeth should be positioned in the face and jaws and how to get them there. J Clin Orthod 1997;31:586-608. 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. Grainger RM. Orthodontic treatment priority index. Washington, DC: US Government Printing Ofce; 1967. Corruccini RS, Potter RH. Genetic analysis of occlusal variation in twins. Am J Orthod 1980;78:140-54. Corruccini RS, Whitley LD. Occlusal variation in a rural Kentucky community. Am J Orthod 1981;79:250-62. Ghafari J, Locke SA, Bentley JM. Longitudinal evaluation of the treatment priority index (TPI). Am J Orthod Dentofacial Orthop 1989;96:382-9. von Bremen J, Pancherz H. Efciency of early and late Class II Division 1 treatment. Am J Orthod Dentofacial Orthop 2002; 121:31-7. Dahlberg G. Statistical methods for medical and biological students. New York: Interscience Publications; 1940. Houston WJB. The analysis of errors in orthodontic measurements. Am J Orthod 1983;83:382-90. King GJ, McGorray SP, Wheeler TT, Dolce C, Taylor M. Comparison of peer assessment ratings (PAR) from 1-phase and 2-phase treatment protocols for Class II malocclusions. Am J Orthod Dentofacial Orthop 2003;123:489-96. Livieratos FA, Johnston LE Jr. A comparison of one-stage and two-stage nonextraction alternatives in matched Class II samples. Am J Orthod Dentofacial Orthop 1995;108:118-31. Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989;11:309-20. Richmond S, Andrews M, Roberts CT. The provision of orthodontic care in the general dental services of England and Wales: extraction patterns, treatment duration, appliance types and standards. Br J Orthod 1993;20:345-50. Richmond S, Shaw WC, OBrien KD, Buchanan IB, Jones R, Stephens CD, et al. The development of the PAR Index (peer assessment rating): reliability and validity. Eur J Orthod 1992;14: 125-39. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR index (peer assessment rating): methods to determine outcome of orthodontic treatment in terms of improvement and standards. Eur J Orthod 1992;14:180-7. Shaw WC, Richmond S, OBrien KD, Brook P, Stephens CD. Quality control in orthodontics: indices of treatment need and treatment standards. Br Dent J 1991;170:107-12. al Yami EA, Kuijpers-Jagtman AM, van t Hof MA. Occlusal outcome of orthodontic treatment. Angle Orthod 1998;68:439-44. Kerr WJS, McColl JH. Use of the PAR index in assessing the effectiveness of removable orthodontic appliances. Br J Orthod 1993;20:351-7. Parkinson CE, Buschang PH, Behrents RG, Throckmorton GS, English JD. A new method of evaluating posterior occlusion and its relation to posttreatment occlusal changes. Am J Orthod Dentofacial Orthop 2001;120:503-12.

274.e8

Janson et al

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34. Hamdan AM, Rock WP. An appraisal of the peer assessment rating (PAR) index and a suggested new weighting system. Eur J Orthod 1999;21:181-92. 35. Janson G, Barros SE, Freitas MR, Henriques JF, Pinzan A. Class II treatment efciency in maxillary premolar extraction and nonextraction protocols. Am J Orthod Dentofacial Orthop 2007;132: 490-8. 36. Janson G, Maria FR, Barros SE, Freitas MR, Henriques JF. Orthodontic treatment time in 2- and 4-premolar-extraction protocols. Am J Orthod Dentofacial Orthop 2006;129:666-71. 37. Lewis EA, Albino JE, Cunat JJ, Tedesco LA. Reliability and validity of clinical assessments of malocclusion. Am J Orthod 1982; 81:473-7. 38. 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. 39. Robb SI, Sadowsky C, Schneider BJ, BeGole EA. Effectiveness and duration of orthodontic treatment in adults and adolescents. Am J Orthod Dentofacial Orthop 1998;114:383-6. 40. OBrien KD, Robbins R, Vig KW, Vig PS, Shnorhokian H, Weyant R. The effectiveness of Class II, division 1 treatment. Am J Orthod Dentofacial Orthop 1995;107:329-34. 41. Shia GJ. Treatment overruns. J Clin Orthod 1986;20:602-4. 42. Janson G, Graciano JTA, Henriques JF, Freitas MR, Pinzan A, Pinzan-Vercelino CRM. Occlusal and cephalometric Class II Division 1 malocclusion severity in patients treated with and without extraction of two maxillary premolars. Am J Orthod Dentofacial Orthop 2006;129:759-67. 43. Skidmore KJ, Brook KJ, Thomson WM, Harding WJ. Factors inuencing treatment time in orthodontic patients. Am J Orthod Dentofacial Orthop 2006;129:230-8. 44. Vig KW, Weyant R, Vayda D, OBrien K, Bennett E. Orthodontic process and outcome: efcacy studiesstrategies for developing

45. 46.

47. 48.

49.

50. 51.

52.

53.

54.

process and outcome measures: a new era in orthodontics. Clin Orthod Res 1998;1:147-55. Nanda RS, Kierl MJ. Prediction of cooperation in orthodontic treatment. Am J Orthod Dentofacial Orthop 1992;102:15-21. Ferreira SL. Class II Division 2 deep overbite malocclusion correction with nonextraction therapy and Class II elastics. Am J Orthod Dentofacial Orthop 1998;114:166-75. Kessel SP. The rationale of maxillary premolar extraction only in Class II therapy. Am J Orthod 1963;49:276-93. Richter DD, Nanda RS, Sinha PK, Smith DW, Currier GF. Effect of behavior modication on patient compliance in orthodontics. Angle Orthod 1998;68:123-32. Vaden JL, Harris EF, Behrents RG. Adult versus adolescent Class II correction: a comparison. Am J Orthod Dentofacial Orthop 1995;107:651-61. Buschang PH, Martins J. Childhood and adolescent changes of skeletal relationships. Angle Orthod 1998;68:199-206. Burkhardt DR, McNamara JA Jr, Baccetti T. Maxillary molar distalization or mandibular enhancement: a cephalometric comparison of comprehensive orthodontic treatment including the pendulum and the Herbst appliances. Am J Orthod Dentofacial Orthop 2003;123:108-16. Chiu PP, McNamara JA Jr, Franchi L. A comparison of two intraoral molar distalization appliances: distal jet versus pendulum. Am J Orthod Dentofacial Orthop 2005;128:353-65. Pancherz H. The effect of continuous bite jumping on the dentofacial complex: a follow-up study after Herbst appliance treatment of Class II malocclusions. Eur J Orthod 1981;3:49-60. Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. A cephalometric investigation. Am J Orthod 1982;82:104-13.