THE “WHITE” PAPER

Analysis of a Class II therapeutic failure

Dr. Larry W. White examines a common outcome of the removal of maxillary and mandibular premolars in
Class II malocclusions

Abstract
Dr. Charles Tweed had enormous influence
in orthodontics by developing a rationale for
the extraction of premolars and the Tweed
Triangle, which he used as a diagnostic and
treatment-planning instrument. He used
the premolar extraction spaces to center
the mandibular incisors in the alveolus at an
angle of 90° ± 3° to the mandibular plane,
and then positioned the maxillary incisors
to occlude properly with them. Figure 1: Typical Class II malocclusion Figure 2: Occlusal result when the mandibular canine oc-
cupies one-third of the extraction space, and the maxillary
Dr. Tweed’s skill and expertise allowed canine has fully retracted
him to build a large cadre of imitators, and
the removal of maxillary and mandibular first
premolars became an accepted protocol
in the treatment of Class II malocclusions
and remains largely unquestioned by
orthodontists to the present time.
Nevertheless, within the past decade,
doubt has arisen about the efficacy of such
a protocol, and the current article will offer
an illustration of a common outcome of
the removal of maxillary and mandibular
Figure 3: Occlusal result when the mandibular first Figure 4: Occlusal result when extracting only the maxil-
premolars in Class II malocclusions. premolar and canine occupy one-third of the extraction lary first premolars. The overjet and overbite can now be
space, and the maxillary canine has fully retracted corrected
Introduction
The enormous influence and innovation established himself as the one of the most realize that only one-third of the extraction
of E. H. Angle continues to this day in formidable and successful along with space need occupation by the retraction
orthodontics. Even his treatment protocol Raymond Begg3,4. of the mandibular canines to make the
of non-extraction therapy has seen a Angle’s non-extraction system had so achievement of Class I canines unusually
recent resurgence that challenges the disappointed Tweed that he retreated many difficult (Figure 2). At this point, only forceful
removal of premolars for the correction of his patients by extracting maxillary and Class II interarch mechanics, e.g., Class
of malocclusions. Tweed was not the first mandibular premolars, and subsequently II elastics, will arrange the canines in a
to challenge Angle’s narrow prescription developed his own diagnostic and Class I relationship. But such mechanics
for universal nonextraction1,2, but he treatment planning procedure, i.e., the will also displace the mandibular arch
Tweed Triangle5-8. more forward, which negates any effort to
Janson,9-14 et al., began to upright the incisors to 90°± 3° relative to the
challenge the efficacy and efficiency of mandibular plane. Growing patients can,
Tweed’s extraction technique for Class of course, benefit from the use of cervical
Larry W. White, DDS, MSD, graduated from
Baylor Dental College, and then served
II malocclusions by showing that the retractors, but this has the disadvantage
for 2 years in the United States Air Force removal of four premolars resulted in longer of retracting not only the entire maxilla but
Dental Corps. He returned to Baylor Dental treatments with less satisfying results also the upper lip16,17.
College and received a graduate degree
in orthodontics, and then practiced in Hobbs, New
than when clinicians chose to remove When limited-growing or non-
Mexico for 31 years. He was the first director of the only two maxillary premolars. Bryk15 had cooperative Class II patients reach this
University of Texas Health Science Center in San earlier illustrated why the removal of four impasse, few remedies remain for the
Antonio’s orthodontic residency program. Dr. White has
published more than 100 professional articles, authored
premolars in Class II malocclusions created clinician to employ, and many will resort
several books about orthodontics, and edited numerous a particularly difficult environment for the to so-called noncompliant devices such
professional publications. He is a Diplomate of the successful resolution of these orthodontic as Saif Springs18, Forsus19, MPAs20,21,
American Board of Orthodontists and a Fellow in the
American College of Dentists. Dr. White has authored
problems (Figures 1-4). Eureka Springs22,23, etc. Unfortunately, at
over 100 clinical articles, lectured in 35 countries, and When clinicians choose to remove this point, patients have been in treatment
was editor of the Journal of Clinical Orthodontics for 17 mandibular premolars in the correction for 1 year or more, and many are suffering
years.
of a Class II malocclusion, they need to from orthodontic fatigue, which makes

24 Orthodontic practice Volume 4 Number 1

 THE “WHITE” PAPER
Figure 5: Adult Class II malocclusion Figure 6: Occlusal result of maxillary first and mandibular second pre-molar
extractions

Figure 7: Mature adolescent patient with a Class II malocclusion Figure 8: VTO illustrating needed movement of the incisors

their cooperation with even noncompliant the truth of these remarks. The following This tempts the clinician to claim
appliances questionable. patient is only one of the many I could, that the poor outcome was the result
Some clinicians have sought to unfortunately, provide, but it is typical of of marginal patient cooperation, but is
avoid this dilemma by removing maxillary the predictable failure that results with the that a satisfactory answer? Might not the
first premolars and mandibular second removal of maxillary first and mandibular questionable consequence be due to the
premolars; but, again, if the mandibular first second premolars in Class II adult, poorly- original treatment plan? In this case, I am
premolar and canine occupy just one-third growing patients or noncompliant patients certain it was.
of the extraction space, the same end-on (Figure 5). This patient displays a Class II A better treatment would have
canine will result (Figure 3). For this strategy malocclusion complicated by maxillary and resulted from the removal of the maxillary
to work, almost all of the extraction space mandibular arch length discrepancies (6 first premolars and interproximal enamel
will need occupation by the molar. mm respectively), which causes clinicians reduction (IER), aka Air Rotor Stripping25 of
Bryk and Janson have suggested the to believe that the extraction of maxillary 6 mm in the mandibular arch. Some might
extraction of only maxillary first premolars and mandibular premolars remains the object to that much polishing of enamel,
as a remedy for this type of malocclusion, only option. Figure 6 shows the result of but it is much more conservative than
which will result in Class I canines and that decision. removing 15 mm of tooth structure through
Class II molars (Figure 4). This strategy The patient now has four fewer teeth, extractions, and multiple studies have
offers a predictable Class II correction of end-on canines, and a slight overjet with shown minimum harmful effects24-27, 28-32
overjet, overbite, and canine position. under-torqued maxillary incisors. Outside of from interproximal enamel reduction; and it
better alignment and a midline correction, would have offered much better occlusion
Therapeutic reports it would be hard to qualify this patient as and a quicker, less traumatic conclusion.
Critics may counter that the above having even a marginal treatment result. The following patient offers a clinical
illustrations are just that and don’t reflect Certainly, it is not one acceptable to illustration of this type of strategy (Figures
clinical realities, but clinicians need the American Board of Orthodontics. By 7-11). The patient displayed a bilateral Class
only view a few of their Class II patients the time the patient needed to use forceful II malocclusion characterized by maxillary
they have treated with maxillary and Class II elastics, she was worn out and was and mandibular arch length discrepancies,
mandibular premolar extractions to see only mildly compliant. a large overjet, and moderate overbite, a

Volume 4 Number 1 Orthodontic practice 25

THE “WHITE” PAPER

Extractions

Figure 9: Modified Steiner box for calculating space needs Figure 10: VTO superimposed on the actual treatment
of this patient result

midline deviation, and a slightly protrusive

soft tissue profile. The Visualized Treatment
Objective (VTO) developed in Figure 8 was
based on a consensus derived from the
Alvarez32, Holdaway16,17 and Creekmore33
treatment planning strategies. All of these
analyses had agreement regarding the
protrusiveness of the maxillary incisors
and the need of the mandibular incisors for
intrusion but to remain in place otherwise.
The Tweed, Steiner, and Ricketts
treatment planning strategies would have
repositioned the mandibular incisors
lingually, which would have required the
removal of mandibular premolars also. The
modified Steiner box in Figure 9 illustrates
the calculations that determined the
need to remove maxillary first premolars
Figure 11: Completed therapy for Class II patient
only, while leaving the mandibular arch
non-extraction and using interproximal
enamel reduction of 4 mm to resolve the
mandibular arch length discrepancy. Figure a decision, clinicians can understand the of mandibular premolars causes patients
11 displays the results of the strategy of difficulty they routinely encounter with to have a vulnerability to root resorption34,35
removing only maxillary first premolars and this strategy. In Class II malocclusions, decalcification36, caries37, and periodontal
using IER to provide space to resolve the the maxillary canines start with a decided problems38.
mandibular arch length discrepancy. Figure deficit by their mesial position vis-à-vis Unfortunately, when clinicians need
10 shows how the final cephalometric the mandibular canines, and the slightest to apply Class II mechanics for these
result coincided with the original VTO. movement distally of the mandibular types of patients, it is after several months
The VTO with cross-hatched replicas canines increases the difficulty in achieving of therapy that has resulted in end-on
of the teeth coincide quite nicely with the Class I canine occlusion. canines. By then, patients can see good
actual treatment result outlined in red. When patients do not or cannot alignment and other corrections in their
This treatment finished in less than 2 years experience substantial mandibular growth malocclusions, and they often display
without the need of Class II elastics or to overcome this inherent deficit, or benefit serious treatment tiredness, and a
mechanics and only a slight amount of time from a retractor that moves the entire reluctance to cooperate in the application
with Class III elastics to bring the maxillary maxilla and/or maxillary dentition distally, of forceful Class II mechanics. It is exactly
molars forward to close the remaining the only remedy left is to apply powerful this common scenario that has resulted
extraction spaces. Class II mechanics, which will displace in the development and popularity of the
the mandibular dentition forward. Such so-called noncompliant appliances, and
Discussion tactics, of course, result in what has clinicians eagerly seek and use them —
The removal of maxillary and mandibular become known in orthodontic parlance as even with their substantial extra cost.
premolars in Class II malocclusions has “round tripping,” and this introduces more Orthodontic clinicians would do well
become such a routine procedure that it treatment time along with the uncertainty of to develop alternative approaches to the
remains almost unchallenged. However, by Class II mechanics side effects, which often treatment of Class II malocclusions that
simply arranging a schematic to illustrate negate their positive contributions. Also, require space to correct their protrusiveness
how difficult positioning the maxillary the additional time required to correct the and/or arch length discrepancies they
canine in a Class I relationship after such end-on canines resulting from the removal often display. Rather than removing

26 Orthodontic practice Volume 4 Number 1

 THE “WHITE” PAPER
mandibular premolars when an arch length • use aggressive Class II interarch would be well advised to remove only
discrepancy exist in Class II malocclusions, mechanics, e.g., Herbst, MPA, Eureka, the maxillary premolars and conclude
clinicians should consider some alternative Forsus, Jasper Jumper, MARA etc; the therapy with the maxillary canines in
strategies such as: • carefully monitor the mandibular a Class I relationship and the molars in
• removal of only the maxillary premolars extraction space, and do not exceed a Class II relationship. At the least, they
combined with IER of the mandibular one-third of it with canine retraction; should approach such therapies with full
teeth; • consider removing maxillary first molars knowledge of the problems they will face,
• correction of the Class II malocclusion in addition to the first premolars; should they elect to remove maxillary and
before removing maxillary and • use Temporary Anchorage Devices, aka mandibular premolars.
mandibular premolars; TADs, to retract the maxillary arch. One final caveat regarding the diag-
• removal of the maxillary second molars nosis and treatment planning of Class II
and retract the entire maxillary arch with Conclusion patients: avoid treatment planning regi-
IER of the mandibular teeth; When orthodontic clinicians design a mens that emphasize restrictive positions
• consider removing a mandibular incisor if Class II malocclusion strategy that involves for the mandibular incisors to the exclusion
occlusograms confirm it. the removal of maxillary and mandibular and neglect of the maxillary incisors, which
When the mandibular arch length premolars, they will inevitably face a have the ultimate responsibility for lip sup-
discrepancy is so large that extractions particular problem in achieving Class I port. OP
must be done, then clinicians can remove occlusion if the mandibular canines occupy
the maxillary first and mandibular second more than one-third of the extraction
premolars and elect one of the following: space. To avoid such a conundrum, they

References in 2-and 4-premolar -extraction protocols. Am J premolar region: the new approach. Aust Orthod J.
OrthodDentofacial Orthop. 2006;129(5):666-671. 1990;11(4):236-240.
1. Case C. Disto-mesial intermaxillary force Chicago
Dental Society. Chicago, IL; 1893. 14. Pinzan-Vercelino C, Pinzan A, Janson G, de 27. Twesme DA, Firestone AR, Heaven TJ, Feagin
Almeida R, Henriques J, de Freitas MR. Comparison FF, Jacobson A. Air-rotor stripping and enamel
2. Case C. Dental orthopedia and correction of cleft of the occlusal outcomes and treatment timeof Class demineralization in vitro. Am J Orthod Dentofacial
palate. New York, NY: Quick Lithographers; 1921. II malocclusion with the Pendulum appliance and with Orthop. 1994;105(2):142-152.
two maxillary premolar extractions. Dental Press J
3. Begg PR, Kesling PC. Begg orthodontic theory and Orthod. 2010;15:89-100. 28. Betteridge MA. The effects of interdental stripping
technique. Philadelphia, PA: W.B. Saunders Co.; 1977. on the labial segments evaluated one year out of
15. Bryk C, White LW. The geometry of Class retention. Br J Orthod. 1981;8(4):193-197.
4. Begg PR, Kesling PC. The differential force method II correction with extractions. J Clin Orthod.
of orthodontic treatment. Am J Orthod. 1977;71:1-39. 2001;35(9):570-579. 29. Jarjoura K, Gagnon G, Nieberg L. Caries risk
after interproximal enamel reduction. Am J Orthod
5. Tweed CH. The Frankfort-mandibular incisor angle 16. Holdaway RA. A soft tissue cephalometric analysis Dentofacial Orthop. 2006;130(1):26-30.
(FMIA) in orthodontic diagnosis, treatment planning, and its use in orthodontic treatment planning. Part I.
and prognosis. Angle Orthod. 1954;24(3):121-169. Am J Orthod. 1983;84(1):1-28. 30. Mikulewicz M, Szymkowski J, Matthews-
Brzozowska T. SEM and profilometric evaluation of
6. Tweed CH. Evolutionary trends in orthodontics, past, 17. Holdaway RA. A soft tissue cephalometric analysis enamel surface after air rotor stripping--an in vitro
present and future. Am J Orthod Dentofacial Orthop. and its use in orthodontic treatment planning. Part II. study. Acta Bioeng Biomech. 2007;9(1):11-17.
1953;39(2):88. Am J Orthod. 1984;85(4):279-293.
31. Germec D, Taner TU. Effects of extraction and
7. Tweed CH. Clinical Orthodontics. St. Louis, MO: C.V. 18. Boley JC, White L. Class II mechanics for nonextraction therapy with air-rotor stripping on facial
Mosby Co.; 1966. noncompliant patients. World J Orthod. 2003;4:206- esthetics in postadolescent borderline patients. Am J
214. Orthod Dentofacial Orthop. 2008;133(4):539-549.
8. Tweed CH. The diagnostic facial triangle in the
control of treatment objectives. Am J Orthod. 19. Jones G, Buschang PH, Kim KB, Oliver DR. Class II 32. Alvarez AT. The A line: a new guide for diagnosis
1969;55(6):105-121. non-extraction patients treated with the Forsus Fatigue and treatment planning. J Clin Orthod. 2001;35(9):556-
Resistant Device versus intermaxillary elastics. Angle 569.
9. Janson G, Carmardella LT, Araki JD, de Fritas MR, Orthod. 2008;78(2):332-338.
Pinzan A. Treatment stability in patients with Class 33. Creekmore TD. Where teeth should be positioned
II malocclusion treated with 2 maxillary premolar 20. Coelho Filho CM, Coelho FO, White LW. Closing in the face and jaws and how to get them there. J Clin
extractions or without extractions. Am J Orthod mandibular first molar spaces in adults. World J Orthod. 1997;31(9):586-608.
Dentofacial Orthop. 2010;138(1):16-22. Orthod. 2006;7(1):45-58.
34. Sameshima GT, Sinclair PM. Predicting and
10. Janson G, Estelito S, Barros S, Simao T, de Freitas 21. Coelho Filho CM. Mandibular protraction appliance preventing root resorption: Part II. Treatment factors.
MR. Variaveis relevantes notratamento da ma oclusao IV. J Clin Orthod. 2001;35(1):18-24. Am J Orthod Dentofacial Orthop. 2001;119:511-515.
de Classe II. Rev Dent Press Ortodon Ortop Facial.
2009;14(4):149-158. 22. Stromeyer EL, Caruso JM, DeVincenzo JP. A 35. Sameshima GT, Sinclair PM. Predicting and
cephalometric study of the Class II correction effects of preventing root resorption: Part I. Diagnostic factors.
11. Janson G, Janson M, Nakamura A, de Freitas MR, the Eureka Spring. Angle Orthod. 2002;72(3):203-210. Am J Orthod Dentofacial Orthop. 2001;119(5):505-510.
Henriques JF, Pinzan A. Influence of cephalometric
characteristics on the occlusal success rate of Class 23. Sheridan JJ. Air-rotor stripping. J Clin Orthod. 36. Mitchell L. Decalcification during orthodontic
II malocclusions treated with 2- and 4-premolar 1985;19:43-59. treatment with fixed appliances—an overview. Br J
extraction protocols. Am J Orthod Dentofacial Orthop. Orthod. 1992;19(3):199-205.
2008;133(6):861-868. 24. El-Mangoury NH, Moussa MM, Mostafa YA, Girgis
AS. In vivo remineralization after air-rotor stripping. J 37. Zachrisson BU, Zachrisson S. Caries incidence and
12 Janson G, Brambilla AC, Henriques JF, de Freitas Clin Orthod. 1991;25(2):75-78. oral hygiene during orthodontic treatment. Scand J
MR, Neves LS. Class II treatment success rate in Dent Res. 1971;79(6):394–401.
2-and 4-premolar extraction protocols. Am J Orthod 25. Crain G, Sheridan JJ. Susceptibility to caries and
Dentofacial Orthop. 2004;125(4):472-479. periodontal disease after posteriorair-rotor stripping. J 38. Bollen AM, Cunha-Cruz J, Bakko DW, Huang
Clin Orthod. 1990;24(2):84-85. GJ, Hujoel PP. The effects of orthodontic therapyon
13. Janson G, Maria FR, Barros SE, Freitas MR periodontal health a systematic review of controlled
and Henriques, JFC. Orthodontic treatment time 26. Jarvis RG. Interproximal reduction in the molar/ evidence. J Am Dent Assoc. 2008;139(4):413-422.

Volume 4 Number 1 Orthodontic practice 27