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Objective: To determine whether, in Class I borderline cases, experienced orthodontists choose nonextraction treatment more frequently than do orthodontists with less experience. A secondary aim was to evaluate whether clinicians' gender and place of education play a role in extraction decision making., Materials and Methods: An online survey was developed using three Class I borderline patient cases. The survey included questions about clinicians' demographics as well as questions about the selected cases. The survey was distributed to approximately 2000 clinicians through the American Association of Orthodontics., Results: Of the 253 responses collected, a trend was observed wherein clinicians with more than 15 years of experience preferred an extraction treatment option more frequently than did clinicians with less than 5 years of experience. There was no association between gender and place of education and the decision to extract in the selected borderline cases. Crowding, patient's profile, and mandibular incisor inclination were among the top three reasons chosen by clinicians for both the extraction and nonextraction treatment decisions., Conclusions: A trend was observed in which clinicians with more experience chose an extraction treatment option more frequently in borderline cases than did those with less experience. Clinicians' gender did not play a role in extraction decision making.

Objective: The objective of this study was to determine the duration of orthognathic-surgical treatment conducted with conventional pre- and post-surgical orthodontic treatment phases., Material and Methods: The study material was comprised of the files of 185 consecutive patients treated in Oral and Maxillofacial Unit, Tampere University Hospital, Finland, in 2007-2014. The files were reviewed and the following data was obtained: gender and age of patients, ICD-10 diagnosis, type of malocclusion, duration of pre- and post-surgical orthodontic treatment and type of operation., Results: Total treatment duration (median) from placement of separating rings for banding until fixed orthodontic appliances were removed and retention period started was 31.1 months, of which pre-surgical orthodontics took 24.4 months and postsurgical 6.4 months. Treatment duration (median) was in BSSO was 32.1, LeFort 1 30.1 and bimaxillary osteotomy 29.7 months. Orthodontic extractions were performed in 35 patients (19%). If the orthodontic treatment included tooth extraction, the duration of pre-surgical treatment was on average 10 months longer, which is a statistically highly significant difference (p < .001, linear regression)., Conclusions: Tooth extractions (excluding 3rd molars) included in pre-surgical orthodontic treatment prolong treatment time by an average of 8-9 months.

Objective: To compare the arch width changes in patients treated fixed orthodontic mechanics without extraction (Group 1), with upper and lower first premolar extractions (Group 2), and with upper first premolar extraction only (Group 3)., Materials and Methods: The study was conducted with pre- and post-treatment digital models from 240 patients. Anterior, middle, and posterior distances were measured on pre- and post-treatment models. At T1 measurements, the distance among the canine cusp tips, the second premolar buccal cusp tips, and the first molar mesiobuccal cusp tips were measured. In addition, the distance (D) between the intercanine and intermolar lines and the distance (D') between the interpremolar and intermolar lines were defined on the anatomic y-axis, and this distance was maintained in calculating posttreatment measurements (T2). Mandibular and maxillary arch width changes were evaluated within and between groups., Results: Anterior, middle, and posterior arch widths increased significantly in Groups 1 and 3. Maxillary anterior and middle arch widths also increased in Group 2, but the increases were not statistically significant. Changes in maxillary anterior and middle arch widths were higher in Groups 1 and 3 when compared to Group 2. However, there was no statistically significant difference in mandibular arch changes between the groups., Conclusion: Extraction treatment mechanics did not cause narrow dental arches, but nonextraction treatment increased arch width in all 3 measurements. Treatments with only upper arch extraction showed similar results with nonextraction treatment.

Objective: As genetic variation accounts for two-thirds of the variation in external apical root resorption (EARR) concurrent with orthodontic treatment, we analyzed the association of selected genetic and treatment-related factors with EARR concurrent with orthodontic treatment., Setting and Sample Population: This case-control study of 134 unrelated, orthodontically treated Caucasian individuals was conducted in part at an Indiana Private Practice, Indiana University and the University of Kentucky., Methods: Utilizing a research data bank containing information from ~1450 orthodontically treated patients, pre- and post-treatment radiographs from 460 individuals were evaluated for EARR of the four permanent maxillary incisors. Sixty-seven unrelated Caucasians with moderate to severe EARR were identified and were age-/sex-matched with orthodontically treated Caucasian controls yielding 38 females and 29 males per group. Factors tested for an association with EARR included the following: 1) treatment duration, 2) extraction of maxillary premolars, 3) numerous cephalometric measurements, and 4) DNA polymorphisms within/near candidate genes in a pathway previously implicated in EARR such as the purinergic-receptor-P2X, ligand-gated ion channel 7 (P2RX7; rs208294, rs1718119, and rs2230912), caspase-1 (CASP1; rs530537, rs580253, and rs554344), interleukin-1 beta (IL1B; rs1143634), interleukin-1 alpha (IL1A; rs1800587), and interleukin-1 receptor antagonist (IL1RA; rs419598) genes. Stepwise logistic regression was utilized to identify the factors significantly associated (significance taken at or less than the layered Bonferroni correction alpha) with the occurrence of EARR., Results: A long length of treatment and the presence of specific genotypes for P2RX7 SNP rs208294 were significantly associated with EARR., Conclusion: EARR occurrence was associated with both genetic and treatment-related variables, which together explained 25% of the total variation associated with EARR in the sample tested., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The prediction of arch perimeter gained when expanding the arch or proclining the anterior incisors is particularly important in the decision of tooth extraction vs nonextraction therapy for orthodontic treatment., Methods: Correlation of the measured perimeter of the maxillary dental arch and the calculated perimeter applying Ramanujan's equation for the perimeter of an ellipse was evaluated with 30 diagnostic casts of untreated maxillary dental arches. Both linear and circumferential measurements were made directly on the midbuccal surface of these maxillary arches., Results: Ramanujan's equation had a high level of correlation when comparing the measured perimeter of the maxillary dental arch and the calculated perimeter with the 0.01 level (1.2% error) using a 2-tailed t test. The results were applied to Ramanujan's equation to predict maxillary arch perimeter gained by expansion or proclination of the incisors., Conclusions: The ellipse is an accurate geometric model of the maxillary arch form. The average amounts of maxillary arch perimeter gained were 0.73 mm per millimeter of intermolar expansion and 1.66 mm per millimeter of incisor protrusion., (Copyright © 2015 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to determine whether there has been an increase in the number of non-extraction cases over recent years and investigate the selection of treatment devices. Patients attending the Department of Orthodontics at Tokyo Dental College Chiba Hospital in whom orthodontic treatment was commenced between July 1989 and July 1990 (Group A) or between June 1998 and May 2003 (Group B) were included in the study. The orthodontic diagnostic records of the patients were examined. Patients requiring orthognathic surgery, those with congenital diseases or cleft palate, and those with an uncertain diagnostic record were excluded. The characteristics, initial age, and classification of malocclusion in the two groups were almost the same. The patients in both groups were further divided into two subgroups: one in which treatment was commenced in mixed dentition and another in which it was begun in permanent dentition. The final therapeutic strategy, that is to say, non-extraction or extraction, was investigated in all groups. The final observation date in the mixed dentition group in Group B was September 2011. No major differences were observed in pattern or type of malocclusion between the two groups. Group B, however, showed an increased rate of non-extraction treatment. A policy of non-extraction was pursued in a higher proportion of patients in whom treatment was commenced in mixed dentition than in those in which it was begun in permanent dentition.

Background: Studies that show frequencies of different orthodontic treatment protocols can be used as valuable parameters in the interpretation of treatment tendency with time. The purpose of this retrospective study was to evaluate all orthodontic treatment planning conducted at the Orthodontic Department at Bauru Dental School, University of São Paulo, Brazil, since 1973, in order to investigate extraction and non-extraction protocol frequencies selected at each considered period., Methods: The sample comprised 3,413 records of treated patients and was evaluated according to the protocol choice, divided into 10 groups: Protocol 0 (non-extraction); Protocol 1 (four first premolar extractions); Protocol 2 (two first maxillary and two second mandibular premolars); Protocol 3 (two maxillary premolar extractions); Protocol 4 (four second premolars); Protocol 5 (asymmetric premolar extractions); Protocol 6 (incisor or canine extractions); Protocol 7 (first or second molar extractions); Protocol 8 (atypical extractions) and Protocol 9 (agenesis and previously missing permanent teeth). These protocols were evaluated in seven 5-year intervals: Interval 1 (1973 to 1977); Interval 2 (1978 to 1982); Interval 3 (1983 to 1987); Interval 4 (1988 to 1992); Interval 5 (1993 to 1997); Interval 6 (1998 to 2002); Interval 7 (2003 to 2007). The frequency of each protocol was compared between the seven intervals, using the proportion test (P < 0.05)., Results: The results showed that 10 protocol frequencies were significantly different among the 7 time intervals., Conclusions: The non-extraction protocol frequency increased gradually with consequent reduction of extraction treatments. The four premolar extraction protocol frequency decreased gradually while the two maxillary premolar extraction protocol has maintained the same frequency of indications throughout time.

Introduction: The length of time that it takes an orthodontist to treat adult patients varies widely., Objective: The aim of this study was to investigate how different variables influence treatment time., Methods: Seventy clinical case reports of successfully treated adult patients were examined. The patients were selected from 4,723 records held by three experienced orthodontists. The influence exerted by the following variables on treatment time was assessed: age, sex, facial pattern, severity of malocclusion (measured by the PAR index), sagittal relationship of canines, type of brackets (ceramic or metal), tooth extractions, missed appointments and orthodontic appliance issues/breakages, the latter being the dependent variable. Assessment was performed by multiple linear regression analysis, followed by the stepwise method with p < 0.05., Results: The number of times a patient missed their appointment (no-show) (R² = 14.4%, p < 0.0001) and the number of appliance issues/breakages (R² = 29.71%, p = 0.0037) significantly affected variability in treatment time, and these two variables together can predict 43.75% (R² total) of the overall variability in treatment time. Other factors, such as canine relationship at the beginning of treatment, bracket type (metal or ceramic), tooth extractions, age at start of treatment, severity of the initial malocclusion, sex and facial pattern had no significant bearing on treatment time., Conclusions: The duration of orthodontic treatment in adults, when performed by experienced orthodontists, is mainly influenced by factors related to patient compliance. However, several factors which were not included in this study may contribute to variability in orthodontic treatment time.

This prospective questionnaire-based study was designed to determine the incidence of patients attending orthognathic combined clinics who have previously had orthodontic treatment, and to assess the impact, if any, this has had on their proposed surgical treatment. Contemporaneous and historical data from consecutive patients at different stages of treatment who were attending clinics at two London hospitals during a three-month period were included. In total 22/56 patients (39%) had previously had orthodontic treatment, and of those, it had had an undesirable effect on the current management of 10 (45%). The effects included a reduced range of dental movements available to orthodontists (8/23, 35%), undesirable extractions (5/23, 22%), and a prolonging of preoperative orthodontics (5/23, 22%). The median age at which previous orthodontic treatment had been started was 13.5 (range 11-26). Nearly a third of patients reported that they had not been advised by their referring practitioner that a combined orthodontic and surgical approach might be required. The study suggests that preliminary assessment should be improved. Patients should be informed about and prevented from undergoing orthodontic treatment that may limit future surgical management, otherwise they may have to face repeated and prolonged orthodontic treatment, unexpected operations, and potential limitations to the outcome of surgical treatment. This could be achieved through the training and education of all practitioners and the development of referral guidelines., (Copyright © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Aim: To assess the long-term stability of orthodontic treatment and some factors associated to posttreatment changes., Methods: Six hundred twenty-seven dental casts of 209 patients were examined with the PAR Index at pretreatment (T1), end of treatment (T2), and at long-term follow-up (T3, mean 8.5 years posttreatment). Friedman test and multiple regression analysis at P < .05 were used to evaluate changes among the time points and factors associated with stability., Results: After orthodontic treatment, the PAR Index improved by 94.2%. No significant change was observed between T2 and T3 (P>.05). However, when the sample was divided into a well- (PAR Index ≠ 3) and a less well-finished (PAR Index >3) group, it was observed that well-finished patients experienced some deterioration (P<.001), whereas the less well-finished ones showed some improvement (P<.05). Even with the deterioration, the well-finished patients still had a better PAR Index at T3 compared to the less well-finished ones. Regression analysis showed that PAR Index at T1 and T2, age at T1, and length of retainer wear had a slight association with occlusal stability (R(2)=0.27). No significant association was observed between stability and length of treatment, length of follow-up, sex, extraction, or third molar status on the other side., Conclusion: Orthodontic treatment is quite stable. Not so well-finished treatments tend to show some improvement and well-finished ones deteriorate some. Well-finished patients still have better occlusal characteristics. Retention contributes to maintenance of the final orthodontic results., (COPYRIGHT © 2009 BY QUINTESSENCE PUBLISHING CO, INC.)

Aims: To determine the association between temporomandibular disorders (TMD) and experiences of jaw injury, third molar removal, and orthodontic treatment, controlling for confounding factors such as age, sex, emotional stress, and oral parafunction., Methods: First-year university students (n = 2,374) were instructed to answer a questionnaire regarding symptoms of TMD, jaw injury, third molar removal, orthodontic treatment, stress, and parafunctional habits. All subjects were classified according to the level of TMD symptoms. Logistic regression was applied to assess the associations of experiences of jaw injury, third molar removal, and orthodontic treatment with presence of TMD symptoms after controlling for age, sex, stress, and parafunctional habits., Results: Of the 2,374 students, 715 students were TMD symptom-positive. They were classified into 7 groups consisting of those with only clicking (group 1), only pain in the temporomandibular joint (group 2), only difficulty in mouth opening (group 3), clicking and pain (group 4), clicking and difficulty in mouth opening (group 5), difficulty in mouth opening and pain (group 6), and all 3 symptoms (group 7). TMD symptoms were significantly associated with jaw injury. Odds ratios were 2.25, 2.47, 3.38, and 2.01 for groups 2, 3, 6, and 7, respectively. Experience of third molar removal was significantly associated with TMD (odds ratio = 1.81 for group 1). No association was found between orthodontic experience and TMD., Conclusion: Experiences of jaw injury and third molar removal might be cumulative and precipitating events in TMD.

In certain orthodontic treatments therapy includes the removal of permanent tooth or teeth. The number of objective studies on assessing extraction frequency is low and values in the international publications range between wide limits. This shows that often the extraction decision in the treatment planning does is not made upon the criteria of evidence-based dentistry. In our practice, a retrospective analysis of treatment plans prepared between the 1st of January 2004 and the 31st of December 2006 (416 cases) has been performed. The overall prevalence of treatments with extraction was 41.59% for all patients, the rate was 51.63% in patients with permanent dentition at the time of the planning. The highest proportion of extraction (49.71%) was found in Class II subdivision 2 cases, and the lowest percentage (30.17%) in Class I cases. The decision for extraction does not seem to be influenced by cephalometric analysis directly. The higher percentage of extraction found in permanent dentition period shows that when we cannot use interceptive treatment alternatives, we are forced to extract tooth more frequently. On the other hand, the lower value in early mixed dentition period can be explained by the relatively higher number of treatments with the aim to avoid extraction.

The provision of a joint orthodontic-restorative hospital service is important in providing a quality service for some dental malocclusions. A prospective survey was carried out of the joint orthodontic-restorative clinic at Mayday University Hospital, during the months of January to August 2005. Data was collected using a data collection form. In total 61 patient's attended 4 joint clinics. Fifty per cent of referrals were by general dental practitioners. The commonest referral reasons were spacing and dental trauma. Over one third of patients were seen within 12 weeks of their referral, whilst two thirds start their treatment within 12 weeks of consultation. The commonest restorative treatment was periodontal therapy, crown and bridgework. Over one third of patients required joint orthodontic and restorative treatment. More than 12% of patients require oral surgery in the form of removal of impacted teeth, exposure of unerupted teeth, placement of bone anchors or orthognathic surgery. Consultation and treatment waiting times could be reduced by the introduction of more clinics and employment of more staff A representative in oral surgery maybe useful with the increase use of bone anchors and mini implants to aid joint orthodontic-restorative treatment. Access to an orthodontic and restorative consultant clinic is useful in providing patients with a high quality of multidisciplinary treatment planning in an efficient manner.

Purpose: This study was conducted to examine the duration of postoperative orthodontic treatment of patients who underwent combined orthodontic and orthognathic treatment and investigate factors that might influence this, to assess the strength of association between preoperative and postoperative orthodontic treatment duration, and to perform a retrospective power calculation to assess the likelihood of this study detecting a clinically significant (weeks) difference., Patients and Methods: Records of patients who had undergone combined orthodontic and orthognathic treatment between 1998 and 2003 (n = 69) were obtained from 3 consultant orthodontists at 3 major hospitals in Leeds, UK. The duration of postoperative orthodontic treatment was calculated as the date of the operation to the date of fixed appliance removal. Variables investigated included patient age and gender, malocclusion, type of operation, presence of open bite, extractions (excluding third molars), hospital, operator, missed appointments/breakages and debonding, and retainer arrangements., Results: The median duration of postoperative treatment was 7.5 months (range, 5 to 11 months). None of the variables clearly affected this duration; no correlation was found between preoperative and postoperative treatment times (r(s) = -.07; P > .05). A retrospective power calculation demonstrated a 57.5% likelihood of this study detecting a difference of 8 weeks between 2 groups., Conclusions: Patients should be informed that the postoperative orthodontic phase of combined orthognathic-orthodontic treatment may last approximately 5 to 11 months. No association was found between preoperative and postoperative treatment duration. Many more patients will have to be recruited to assess whether specific variables result in a clinically significant difference in treatment duration.

Changes that occurred in the pattern of tooth extraction in the last 13 years among a population of children in Nigerian were studied. The result of this study was then compared to that of a past study done in the same institution 13 years earlier. Information on age, gender, and indication of tooth extraction was collected prospectively from 379 consecutive patients who visited the outpatient Pediatric Dental Clinic for the first time during the year 2002. Results showed tooth extraction due to caries decreased, while there was an increase in tooth extraction from an apparent increase in orthodontic treatment needs. Acute necrotizing ulcerative gingivitis (ANUG), a significant cause of tooth loss in the last decade, decreased significantly. The pattern of deciduous tooth loss also changed as more anterior teeth were lost for orthodontic reasons in this present study. The pattern of tooth loss in the permanent dentition remains very similar to that of the past study, though more premolars were lost in the present study. There appears to be an increasing need for tooth extractions in orthodontic treatment for this population of children. The focus of planned dental health care provisions, treatment policies, and training emphasis in child dental care may need to shift to addressing orthodontic needs.

Objective: To assess the demand and pattern of referral for orthodontic services at University College Hospital, Ibadan, Nigeria., Design: A 21-month prospective clinic-based study of consecutive orthodontic patients., Setting and Sample Population: The orthodontic clinic of University College Hospital, Ibadan, Nigeria. One hundred and seventy-eight (178) consecutive patients, consisting of 79 (44.4%) males and 99 (55.6%) females with mean age of 16.21+/-7.81 years were studied., Results: 80% of subjects were 20 years of age or younger, while less than 2% were over 40 years of age. More females sought orthodontic care than males. Over 43% of the patients needed removable orthodontic appliances while close to 17% required treatment with fixed appliances. Extractions of retained primary teeth and other grossly malpositioned teeth accounted for 9.6% while 24.7% needed observation of occlusal developments before any treatment decisions could be made. Dentists were noted to be the main referrers of these patients, accounting for over 49% of the referrals, followed by 25.4% who were self referred, and 18.3% who attended under parental influence., Conclusion: More girls than boys demanded orthodontic care and dentists were the major referrers of orthodontic patients.

The purpose of this study was to investigate changes in arch length, arch area, and irregularity index in patients treated with and without premolar extractions. Records collected at pretreatment, at bracket removal, at the end of retention, and 5 years out of retention were examined. Stone casts were mounted on an articulator with an anatomic face-bow and a central wax record, and measurements were made with a 3-dimensional digitizer. In general, the maxillary arch exhibited less relapse tendency than did the mandibular arch for both patient groups. In general, the extraction group showed the same relapse tendency as the nonextraction group.

The purpose of this study was to investigate the changes in palatal volume and palatal height in patients treated with and without premolar extractions. Records were collected at pretreatment, at bracket removal, at the end of retention, and 5 years out of retention. Stone casts were mounted in a SAM 2 articulator with an anatomic face-bow and a central wax record, and measurements were made with a 3-dimensional digitizer. The hypothesis, that orthodontic treatment with premolar extractions changes the palatal form, was verified. Increases in palatal volume and height were demonstrated in the nonextraction group. The extraction group showed a decrease in palatal volume but could compensate for some loss by an increase in volume in the anterior segment.

The purpose of this study was to investigate changes in the palatal form in patients treated with and without premolar extractions. Records collected at pretreatment, at bracket removal, at the end of retention, and 5 years out of retention were examined. Stone casts were mounted on an articulator with an anatomic face-bow and a central wax record, and measurements were made with a 3-dimensional digitizer. The hypothesis that orthodontic treatment with premolar extractions changes the palatal form was verified.

This study compared the occlusal success rate of Class II orthodontic treatment results with either 2- or 4-premolar extraction protocols. Group 1 comprised dental study models of 81 patients treated with 2 premolar extractions, and group 2 comprised dental study models of 50 patients treated with 4 premolar extractions. The initial mean ages of the groups were 13.9 and 12.9 years, respectively. Grainger's treatment priority index (TPI) was used to assess the initial and final occlusal status of each patient. Individual variables, such as maxillary canine anteroposterior positioning, overjet, and overbite improvements were also evaluated. Independent t tests were used to compare the variables at the pretreatment and posttreatment stages and their improvement between the groups. The results showed a statistically significant difference in most of the variables and in their improvement at the end of treatment between the groups. The variables showed a better dental relationship in group 1, and the improvements in group 1 were larger than in group 2. Treatment of Class II malocclusion with 2 premolar extractions gives a better occlusal success rate than treatment with 4 premolar extractions.

With the increasing provision of orthodontic care in this country, certain practitioners have raised concerns regarding the use of elective extractions and retraction mechanics, especially the effects on the facial profile and the TMJ. The non-extraction versus extraction debate spans the history of orthodontics, and the concepts of facial attractiveness are subject to change as fashions change. Within the realms of evidence-based practice, there is little or no evidence to suggest that the philosophies and mechanics of contemporary orthodontics, in the vast majority of cases, cause damage to the profile or are directly linked to the development of TMJ dysfunction.

Aim: The aims of the study were to evaluate 1) the uptake of general anaesthesia 2) the dental factors influencing use of general anaesthesia for routine orthodontic extractions., Research Design: Retrospective cross-sectional., Participants: All patients, aged 16 years and under (n=145), currently undergoing orthodontic treatment at the University Dental Hospital of Manchester, who had received extractions, for their current course of treatment., Method: Patients were asked to complete a questionnaire after appliance adjustment., Main Outcome Measures: 1) type of anaesthesia received for the most recent orthodontic extractions 2) whether a choice of anaesthesia was given 3) number of permanent teeth removed for the current course of orthodontic treatment 4) previous experience of general anaesthesia., Results: The response was 87%. Twenty-two per cent of patients received general anaesthesia, 64% local anaesthesia and 14% inhalation sedation. Sixty-five per cent of patients were not given a choice of anaesthesia for extractions. Stepwise logistic regression analysis revealed that a patient was more likely to receive a general anaesthetic if: 1) they had received a GA in the past (for fillings or extractions) 2) more than four teeth were extracted., Conclusions: Local anaesthesia was predominantly used for orthodontic extractions although the use of general anaesthesia was still quite high. The majority of patients were not given a choice of anaesthesia for routine extractions. Previous exposure to general anaesthesia and removal of more than four teeth increased the likelihood of a patient receiving general anaesthesia.

Background: Current trends in orthodontic care emphasize alternatives to the extraction of premolars, despite a lack of support from the refereed literature for many of the nonextraction treatments., Description of the Situation: Anecdotal reports published in non-peer-reviewed journals have called into question the esthetic effects of extraction treatment. As calls for evidence-based treatments increase throughout dentistry, reports on the effects--both positive and negative--of different orthodontic options have appeared in growing numbers., Clinical Implications: Given the results of a variety of reports in the peer-reviewed literature, it may be concluded that orthodontic treatment involving extractions can produce improved esthetics for many patients who have some combination of crowding and protrusion. However, careful diagnosis followed by evidence-based treatment decisions should be the accepted clinical norm as the specialty of orthodontics embarks on its second century.

There is seldom a consensus on any dental subject. The literature contains conflicting points of view and results of studies vary considerably. I have endeavored to present my paradigm of second molar replacement in dentofacial orthopedics and orthodontics. I have presented a summation of information known to date regarding this subject. I based this article on my extensive clinical experience and observations over many years. I participate in continuing education, and know many of the traditional and functional post-doctoral educators. I read the literature. For your benefit, I have presented this information and shared a paradigm that has positively changed my life, and perhaps will change the way you practice. Second molar replacement technique has revolutionized orthodontic treatment. The technique offers distinct benefits considering the patient's face, the jaw joints, and the teeth. The reader is strongly encouraged to read bibliography references for a mature understanding of second molar replacement in modern orthodontics and TMD therapy. When extraction of teeth is needed for orthodontic purposes Broadbent considers second molar replacement, second bicuspid removal, first bicuspid removal, lower incisor removal, and then other extraction possibilities to resolve the malocclusion. When extraction guidelines are followed and treatment mechanics are properly designed the extraction of second molars have predicable good results in a high percentage of cases. However, second molar removal may be contraindicated for numerous reasons. Diagnosis and case selection is paramount! The doctor must diagnosis and determine if and when second molar replacement would be in each patient's best interest. The bottom line for each individual patient is the best possible facial esthetics, functional occlusion, and health of jaw joints.

The purpose of this article is to review some of the pertinent studies related to the management of third molars in an orthodontic context. The clinician should base his or her decision to extract or not extract third molars on the most current scientific information and what is best for each individual patient.

The purpose of this study was to evaluate the effects of different growth pattern and treatment type factors on craniofacial structures in cases treated with fixed mechanics and premolar extractions. A total of 41 cases with a mean chronologic age of 14 years 7 months and skeletal age of 14 years 6 months was included in the study. These cases were treated with fixed Edgewise mechanics and with extraction of four first premolars. The growth pattern factor was assessed in two levels as mesiodivergent and hyperdivergent, and the treatment type factor was assessed as with and without headgear. The results were analyzed by two-way analysis of variance. In the assessment of differences between the two types of growth patterns at the end of treatment; the changes in N-ANS and N-M were found to be statistically significant (P <.05). In comparison of cases treated with and without headgear, changes in SNA and ANB angles were found to be statistically significant (P <.01). Interaction was found to be nonsignificant for all measurements. It was observed that treatment with fixed appliances and premolar extractions does not change significantly the growth pattern.

The purpose of this study was to examine diagnosis and treatment planning categorizations used by experienced orthodontists. Thirty-nine clinicians were asked to evaluate six test cases and formulate a diagnosis and treatment plan for each. The information provided was categorized using a problem-oriented classification. The results indicate little agreement exists in diagnostic subcategories, such as molar relationship, degree of crowding, or the nature of skeletal discrepancies. There was also little agreement regarding some treatment strategies, such as extraction of teeth, the use of orthopedic appliances, or the use of surgery. A need exists for better definitions of diagnostic criteria and appropriate treatment options.

The extraction of teeth for orthodontic purposes has always been a controversial subject in the specialty. The purpose of this study was to assess the outcome of orthodontic treatment in 100 patients treated with the extraction of four premolars and compare it with the outcome of 100 patients treated without extractions, using the peer assessment rating (PAR) index. Records were selected from 1,198 consecutively completed cases treated by a single provider (MGH) between 1981 and 1995. We chose the first 100 finished patients in each group (extraction and nonextraction) who were under the age of 16 and had no deciduous teeth at the start of treatment. The results of this study show that average treatment time for the extraction group was 29.7+/-6.1 months compared with 26.0+/-7.2 months for the nonextraction group. The extraction group had significantly higher initial PAR scores (T1-PAR ext = 30.01+/-8.20 vs. T1 PAR nonext = 25.21+/-8.55), with greater initial maxillary anterior crowding (PAR ext value = 6.05+/-3.85 vs. PAR nonext value = 4.21+/-2.90) and greater initial overjet (PAR ext value = 1.82+/-1.01 vs. PAR nonext value 1.28+/-1.04). All pretreatment differences were significant at the p < or = 0.0001 level. Although significantly different at the beginning of treatment, both groups were statistically identical at the end (PAR T2 ext = 6.18 + 3.04% reduction = 79.4% compared with PAR T2 nonext = 5.64 + 3.08% reduction = 77.6%). In conclusion, the results demonstrate that, given an additional 3 months of treatment, it is possible for an orthodontist to produce dento-occlusal relationships in extraction patients that are as good as those achieved in nonextraction cases.

The development of process and outcome measures in orthodontics lends itself to retrospective clinical studies. Once valid and reliable measures have been tested, prospective studies may utilize these measures to assess the quality of orthodontic treatment outcome and the duration and process of treatment. The findings from two retrospective studies comparing the quality of outcome using the peer assessment rating (PAR) occlusal index and duration of treatment are reported. Class I and Class II treatment comparisons indicate the duration of treatment time is increased on average 5 months in Class II, division 1 patients. In the second study, the effect of extraction/non-extraction treatment in a sample that included all types of malocclusion indicates that, on average, treatment time is increased by approximately 5 months when extractions are included as part of the orthodontic treatment plan.

In this study we compared the posttreatment stability of occlusion in adults and adolescents treated for crowding or maxillary protrusion with four-premolar extractions and edgewise mechanics at an average of more than 4 years out of treatment. The adolescent sample showed a significantly greater posttreatment increase in mandibular anterior crowding than the adult sample. Posttreatment overjet and overbite remained more stable in the adolescents. We noted a correlation between in-treatment expansion and posttreatment narrowing of mandibular intercanine width in the adults. Differences in postorthodontic occlusal changes were noted between the adult and adolescent samples.

This study addresses the problem of randomization of subjects with respect to an irreversible aspect of treatment strategy, namely, the extraction of teeth. The investigation includes both prospective and retrospective components. The data presented focus on clinician decision-making. Of the 1321 potential subjects for whom records were taken, 250 met the inclusion criteria. Of these subjects, 82 declined to participate and 20 were dropped because of difficulty in obtaining five independent evaluations of their records within a reasonable time frame. Thus, the final sample contained 148 subjects. Approximately one-third of the subjects in the sample are adult, somewhat more than half are female, and Class I malocclusions outnumber Class II malocclusions by a count of 95 to 53. Patterns of agreement and disagreement among five clinicians include: a) agreement/disagreement on the primary decision whether or not to extract: the data reveal a strong tendency towards consensus among the clinicians; b) agreement/disagreement on extraction pattern in patients in whom the clinician believes that extraction is indicated: the clinicians tended strongly to agree on extraction pattern; c) agreement/disagreement on the need for adjunctive orthognathic surgery: decisions favoring surgery were more common and more 'definite' than 'probable' in the adult cohort than in the adolescent cohort but this tendency was not as strong as had been anticipated; d) agreement/disagreement concerning Angle classification: disagreements were more common than had been anticipated; and e) differences among the individual clinicians as to their ratios of extraction/non-extraction decisions: overall, clinicians opted for extraction less frequently in the adolescent cohort than in the adult cohort (55 vs. 66%). Because the data are drawn from actual clinical experience, the conclusions involve a number of assumptions and their generalizability should be evaluated.

African American orthodontic patients often present with morphologic characteristics that prompt the extraction of premolars. Referring dentists, however, commonly see extraction as a cause of "dished in" profiles, collapsed arches, and temporomandibular dysfunction. If true, these claims imply that African American patients are disproportionately at risk of clinical misadventure. Unfortunately, a meaningful long-term comparison of alternative treatments--be it retrospective or prospective--requires samples of patients who were equally susceptible to the two alternatives. Thus, if a retrospective study is to be free of susceptibility bias, the samples must be matched with respect to the anatomic differences that prompted the clinicians' choice of treatments. The goals of this investigation, therefore, were the following: to gather a large sample of African American expatients and to identify by means of discriminant analysis the characteristics that seem to have been important to the extraction decision, to use this knowledge to assemble subsamples of extraction and nonextraction expatients (both Class I and II) who were similar before treatment, and, finally, to recall them so that the long-term impact of the two strategies could be compared. In the end, 60 expatients--30 extraction and 30 nonextraction--were recalled, on average, nearly 8 years after the completion of treatment. In general, both treatments reduced irregularity and neither seemed to produce posterior mandibular displacement. Premolar extraction led to a modest reduction in dental and soft tissue protrusion (half the incisor retraction minus one); nonextraction, by way of contrast, produced an increase. Long term, the difference between the two treatments was about 2 mm at the upper lip and 4 mm at the lower. Excessive profile flattening was not a common finding. Our findings thus imply that the various "functional orthodontic" arguments against premolar extraction do not apply to African Americans any more than they do to whites.

Patients with dentoalveolar asymmetries can present some of the most biomechanically challenging situations to the orthodontist. One creative approach for managing dental asymmetries is to extract a combination of teeth that will simplify intra-arch and interarch mechanics. Often this will also reduce the dependency on patient compliance for elastic wear and may even shorten treatment time. Atypical extraction patterns can also be beneficial in the presurgical orthodontic preparation of orthognathic surgery patients. Multiple diagnostic scenarios are discussed, and various treatment plans involving asymmetric extraction patterns are reviewed.

The meta-analysis technique of literature review was applied to a total of 26 previous studies to assess the longitudinal stability of postretention mandibular intercanine width. Weighted averages and standard deviations for the means of 1,233 subjects were compared for linear changes in intercanine transverse dimensions during treatment (T1), immediately after treatment (T2), and after removal of all retention (T3). Net change was defined as the difference between means at T3 and T1. Dimensional changes were also evaluated on the basis of patient pretreatment Angle classification, extraction, and nonextraction treatment modalities of each group. Paired two-tail t-tests were performed between T3 and T1 means on all groups at the a priori level of significance set at a < or = 0.05. Statistically significant differences were observed for the following groups: all patients; nonextraction; extraction; Class I; Class I extraction; Class II extraction; and, Class I Division 1 nonextraction. The findings of this study indicate that regardless of patient diagnostic and treatment modalities, mandibular intercanine width tends to expand during treatment on the order of one to two millimeters, and to contract postretention to approximately the original dimension. While statistically significant differences could be demonstrated within various groups, the magnitudes of the differences were not considered clinically important.

The aim of the present study was to study profile changes following orthodontic harmonization of enlarged overjet and to attempt to trace predictive aspects regarding prognosis of the soft tissue changes. Lateral cephalograms and study models of 40 female patients, at least 12 years old at the start of treatment, with an overjet of > or = 6 mm were analyzed before (T1) and after treatment (T2). Twenty patients were treated without extractions, while in the remaining 20 patients extractions of premolars were carried out bilaterally in both jaws. The 2 groups were found to be highly homogeneous as regards overjet, cephalometric characteristics, space condition in the upper arch at T1 and both at T1 and T2 as regards age. The most striking aspect of the findings was the considerable amount of variability of the soft tissue changes. These changes were found to be rather unpredictable for the individual patient, since the regression models employed could give only a very wide individual prediction range. The relatively small changes registered, using superimposition methods, in both groups as regards the sagittal position of the lips in comparison to the very strong changes observed in relation to the esthetic line shows that the influence of the growth of the chin and/or the nose on the facial profile might be more important than the influence of the orthodontic treatment. The interpretation of the findings in the present study suggests that, apart from marked cases of skeletal convexity or concavity, the extraction versus non-extraction decision should be based primarily upon current knowledge of long-term stability of orthodontic treatment results.

Recent surveys of children have shown the use of general anaesthesia for extractions by GDPs has declined while its use in hospitals may actually have increased. Shaw and Weatherill argue the aim should be to reduce its use.

As part of an ongoing prospective clinical trial of conventional orthodontic treatment, the decision making patterns of a representative group of orthodontic clinicians were examined. Data were available for 148 subjects (100 adolescents and 48 adults) who had presented at the University of California San Francisco Graduate Orthodontic Clinic requesting treatment for correction of a Class I or Class II malocclusion. The records for each subject were evaluated independently by each of five members of the clinical faculty, making available a total of 740 independent patient evaluations. With regard to the primary decision as to whether extraction or nonextraction treatment was to be preferred, agreement among clinicians was higher than had been anticipated. In almost two thirds of the cases, the decisions of all five clinicians were in agreement as to whether extraction or nonextraction was the preferred treatment modality. (This figure included 59 cases of complete agreement for extraction therapy (40%) and 38 cases of complete agreement for nonextraction therapy (26%)). In only 51 cases (34%), did the reviewing clinicians disagree as to whether extraction or nonextraction was the preferred modality of treatment. The clinicians were also asked to indicate their opinions as to whether orthognathic surgery was likely to be a part of the ultimate treatment course for each individual subject. Nine percent of the 740 patient evaluations contained a clinician judgement that surgery would be a probable or definite component of the orthodontic treatment plan. For 29% of the adult subjects (14 cases) and 23% of the adolescent subjects (23 cases), one or more of the five examining clinicians believed that adjunctive surgical intervention would probably or definitely be appropriate. These high values were unexpected, particularly because the sample had been prescreened by a single clinician to exclude subjects who might require orthognathic surgery. Clinician agreement of Angle classification was also evaluated. Disagreements were observed in 14 adult subjects (29%) and 27 adolescent subjects (27%). Little association was observed between clinician agreement on Angle classification and clinician agreement on whether or not to extract.

In a review of consecutive charts at 5-year intervals from the orthodontic clinic at the University of North Carolina, the number of patients with extraction of all four first premolars increased from 10% in 1953 to 50% in 1963, remained at 35% to 45% until the early 1980s, then declined sharply to the 1950s level by 1993. Extraction for camouflage of Class II malocclusion (maxillary first premolars alone or maxillary first-mandibular second premolars) reached 16% in 1968, then declined, but not as dramatically, and presently is as frequent as the extraction of four first premolars. The rate of extraction of other teeth, done for a variety of individual reasons, has remained almost constant at about 15% for the past 40 years. Thus the total extraction percentage was 30% in 1953, peaked at 76% in 1968, and declined again to 28% in 1993, with almost all the change in the percentage of four first premolar extractions. The increase in first premolar extractions occurred primarily in a search for greater long-term stability; the recent decline seems due to a number of factors. Greater concern about the impact of extraction on facial esthetics, data to suggest that extraction does not guarantee stability, concern about temporomandibular dysfunction, and changes in technique all seem to have played a role. With appropriate orthodontic mechanics, many patients with Class I crowding can be treated satisfactorily with or without premolar extraction.

A systematic sample of 1010 cases was collected by the Dental Practice Board. The commonest type of treatment involved extraction of the first premolars followed by removable appliances. Treatment duration was on average 1.9 years, one-arch fixed appliances were started in an older age group and two-arch fixed appliance treatment took longer to complete than other appliance types. The best standard of treatment was achieved using upper and lower fixed appliances.

The background to current specialist training programmes in orthodontics in the United Kingdom and France is discussed, and the examination structure in the two countries compared with reference to those pertaining in Glasgow and Strasbourg. A sample of 40 of the most recently treated cases submitted by students in each of these two Universities for their final examinations is compared revealing marked differences in case type and treatment philosophy. The differences are explained, to some extent, by the circumstances pertaining to the delivery of orthodontic care in the two countries.

The aim of the present study is to describe the changes in the Holdaway angle during and after treatment with a fixed appliance and to search for any possible differences between non-extraction treatment and extraction treatment. Thirty-five randomly selected Angle Class II. Division I cases with complete records before treatment, at the end of treatment, and at time at least one year out of retention, were collected. The sample was divided into two groups, one consisting of nineteen non-extraction cases and the other group of sixteen extraction cases. All cephalometric radiographs were traced on to acetate film and a computer program developed for cephalometric analysis according to the Bergen Technique was used to evaluate the radiographs. A computer program was used for the statistical evaluation of the data. In conclusion it can be said that no significant differences with regard to the Holdaway angle were found between fixed appliance therapy with or without extraction. A significant influence on the Holdaway angle itemed from the sagittal base relation (ANB) and chin prominence. It seems reasonable to assume that only orthopaedic appliances that influence sagittal base relationship, and especially the lower jaw, can have a profound influence on Holdaway angle.

This study involved the development of a questionnaire to elicit information about current trends in orthodontic practice compared with trends of 5 years ago. The subjects addressed included the use of fixed appliances, functional appliances, extraction therapy, orthodontics and the temporomandibular joint, current diagnostic aids, and medicolegal implications of orthodontic treatment. The questionnaire was mailed to 1400 orthodontic specialists who were randomly selected from across the United States. There were 814 questionnaires returned, representing a 58.14% response rate. The major results of this survey are as follows: (1) The reported extraction rate has declined from a mean of 37.74% 5 years ago to 29.28% today. (2) TMJ concerns (or medicolegal implications thereof) have had a considerable impact in this decline, with 26.4% of orthodontists being influenced, to some extent, to extract fewer teeth because of this factor. (3) The use of functional appliances has remained somewhat static over the last 5 years, after a period of rapid growth in the 5 years previous to that. (4) The preadjusted edgewise appliance is by far the most popular fixed appliance in use today, being chosen by 72.6% of respondents. Analysis of the overall results lead to the following conclusions: (1) Fixed appliance therapy is the therapy of choice of the overwhelming majority of orthodontists. The use, benefits, and role in orthodontics of functional appliance therapy is considerably less defined. (2) Treatment modalities, notably on the use of extraction and its relationship to the health of the temporomandibular joint, should be determined by research, not by legal fears or unsubstantiated allegation.

Contemporary orthodontic practice is diverse, both in the variety of clinical problems treated and in the methods used. Practices differ with respect to their patient composition as well as in many variables relative to treatment protocols. Such heterogeneity makes it difficult to make valid generalizations concerning the characteristics of orthodontic treatment procedures or outcomes; yet data and methods are required for assessment of issues of efficacy and utility. The frequency of orthodontic extractions is an objective criterion that distinguishes practices and may also be related to differences in treatment outcome variables, such as duration. Following a telephone survey to estimate extraction rates in the practices of 238 Michigan orthodontists, five practices with very high or low reported rates were chosen for this pilot study. Our primary aim was to determine whether a systematic relationship existed between the relative frequency of extraction treatments and the duration of active appliance therapy. Records of 438 patients from these practices were examined. The extraction rates of the practices ranged from a low of 25% to a high of 84%. Treatment duration was affected by several variables, such as the number of arches treated, the number of treatment phases, and the practice selected. When the data for all five practices were pooled, and all of the extraction versus nonextraction treatments were compared, the mean durations of treatment were 31.2 and 31.3 months, respectively. Data from individual practices, however, indicated that extraction treatment in each of the practices was of longer duration than nonextraction therapy. These differences in duration were 3.0, 6.6, 2.4, 3.0, and 7.3 months in the five practices.(ABSTRACT TRUNCATED AT 250 WORDS)