Source: AJO-DO on CD-ROM (Copyright 1998 AJO-DO), Volume 1992 Jan

( Premolar extraction and mandibular position - Luecke and Johnston

-------------------------------The effect of maxillary first premolar extraction and incisor retraction on mandibular
position: Testing the central dogma of "functional orthodontics"
Percy E. Luecke III and Lysle E. Johnston, Jr.
San Antonio, Texas, and Ann Arbor, Mich.
It has been argued by a vocal coterie of disaffected dentists that premolar
extraction, incisor retraction, and "backward-pulling" mechanics conspire to
"distalize" the condyles and, pari passu, to produce craniomandibular dysfunction.
Given the gravity of this conjecture, it seemed appropriate to test the predictions it
generates in a sample of patients of the type most often said to be at risk: 42
"edgewise" patients with Class II, Division 1 malocclusions, treated in conjunction
with the extraction of two maxillary first premolars. Regional and anterior cranialbase cephalometric superimpositions were used to quantify the individual
components of the molar and overjet corrections, to measure both at the chin and
condyles the mandibular displacement seen during treatment, and to examine the
extent to which this displacement is related to the correction of maxillary incisor
protrusion. Although the present patients underwent marked upper incisor
retraction (on average, about 5 mm), lip retraction was much less pronounced, and
70% of the sample showed a net forward displacement of mandibular basal bone.
Significantly, changes in condylar position were not correlated with incisor
retraction, as the functional orthodontists" would have it, but rather with the
changes in the buccal occlusion and the growth of the maxilla. Thus, 30% of the
patients who showed evidence of distal displacement were generally nongrowing
patients who underwent more than average anchorage loss in the mandible and
less than average loss in the maxilla. Regardless of the direction of basal
displacement, however, condylar remodeling apparently served to stabilize the
spatial position of surface landmarks (e.g., condylion), an observation that
underscores the futility of using any type of serial radiograph to assess changes in
condylar position in the growing, unimplanted patient. (AM J ORTHOD DENTOFAC
ORTHOP 1992;101:4-12.)
Upper first bicuspids are extracted in my practice. The only teeth which require
extensive movement therefore are the six upper front teeth, which are forced back
to close spaces and correct the facial outlines. During this process the buccal teeth
are adjusted to an interdigitating occlusion which answers all the demands of
mastication, and, what is more, the positions of the teeth are easily retained.
C.S. Case1

In Susan's case with her type of malocclusion or her type of problem when she went
to see the orthodontist, no way should headgear and retraction of the upper front
teeth back toward the tongue have occurred. This left Susan with a bite that her
lower jaw now bites in a displaced position, and no way should any patient be left in
that condition. This is a strong breach this is dental negligence.
J.W. Witzig2
Over the past few years, a variegated assortment of dentists campaigning under
the banner of "functional orthodontics" have assisted in the formulation of a
nettlesome and surprisingly popular legal theory that premolar extraction, extraoral
traction, and Class II elastics combine to produce a distal displacement of the
condyle that ultimately leads to a variety of debilitating craniomandibular disorders
(CMD).3-7
Although this improbable reincarnation of Costen's syndrome8 is largely innocent of
support in the refereed literature, its proponents appear to have won the hearts,
minds, and patients of a good many referring dentists. In the process, they have
convinced a growing segment of the specialty that a willful failure to honor the
tenets of their distal-displacement theory is directly responsible for the various
adverse CMD judgments that currently terrorize the ranks. In increasing numbers,
orthodontists have responded to this double-barreled economic threat by
abandoning premolar extraction,9 even though decades of literature argue that
flaring and expansion, essentially the alternative suggested by the functional
orthodontic counter-culture, is a highly unreliable answer to the problem of
crowding and protrusion.
Although this seemingly mean-spirited attack is reminiscent of La Rochefoucald's
claim that "it is not enough to succeed; others must fail," its long-term success will
turn less on its ability to strike fear in the heart of the unbeliever than on the joint
truth of its component assertions: that premolar extraction causes distal
displacement of the mandible and that this distal displacement in turn causes CMD.
On the face of it, neither seems particularly likely, especially given that the
traditional gnathologic criticism of conventional, specialist-only techniques is that
they tend to cause mesial, rather than distal, mandibular displacement.10-17
The functional orthodontists, however, reserve their most aggressive and pointed
criticism for treatments that emphasize incisor retraction, a change that is
commonly said to "lock" or "trap" the mandible in a retruded position.4 Thus,
despite a record of apparently successful service dating back to Bourdet and Hunter
in the middle of the 18th century, maxillary first-premolar extraction treatments
and the orthodontists who use them are apparently now at risk of being blamed
for any subsequent functional misadventures that their patients may suffer. Given
that a considerable proportion of the population perhaps a half or more will at
one time or another display the signs and symptoms of CMD, regardless of

treatment history,18,19 it is clear that this legal strategy has the potential to do
great mischief to the rational, orderly practice of orthodontics.
Unfortunately, the literature has little of significance to say about the imaginative
concept of "trapped" mandibles; however, from an analysis of ancillary data, it is
possible to conduct at least a preliminary examination of this first link in the
functional orthodontists' hypothesized chain of disaster. Specifically, given the letter
of the Witzig/Yerkes conjecture, one would expect to see a distal displacement of
mandibular basal bone that is closely correlated with the retraction of the maxillary
incisors. Such an outcome, however, clearly would run counter to the neurobiology
of occlusion and the known effects of conventional fixed appliance treatment.
First, given the pronounced overjet of the usual Class II malocclusion, the incisors
could undergo marked retraction without touching, much less trapping, anything.
Indeed, it seems more likely that a patient's centric occlusal position would be
determined by the cusps and fossae of the teeth that actually do occlude the
premolars and molars (in concert with the innervation of their periodontal ligaments
and the muscles of mastication). Accordingly, one would expect that the forward
growth of the midface (1 to 2 mm) and anchorage loss from reciprocal closure of the
maxillary extraction spaces (2 to 4 mm) would combine to produce a marked mesial
movement of the buccal occlusion that should in turn tend to produce an anterior
functional shift of the mandible, including its condyles.20,21 To a lesser extent, this
tendency to forward displacement would be offset by allowing the mandible to
"settle" 1 to 2 mm back into a full step Class II occlusion and by mandibular
anchorage loss. By way of explanation, it should be noted that, in Class II
treatments, lower anchorage loss usually helps to correct the molar relationship and
thus is thought of as mesial molar movement relative to basal bone. In contrast,
maxillary premolar extraction treatments leave the molars in a Class II relationship.
Thus, if the molar relationship is effectively fixed, any mandibular anchorage loss
would, of necessity, take the form of a distal displacement of the mandible. In the
end, however, it can be argued that mesial displacement would be the most
probable net effect of all these treatment changes.
Ultimately, however, reason and logic have their limits, especially at a time when
the specialty appears to have developed what amounts to a siege mentality
concerning the question of extraction; a more direct and timely approach is needed.
Thus it will be the purpose of this article to examine cephalometrically the dental
and skeletal changes produced by the treatment of Class II, Division 1 malocclusions
in conjunction with the extraction of upper first premolars. In the process, we will
examine the alternative hypothesis that this treatment tends to feature instead a
mesial mandibular displacement caused by changes in the position of the buccal
segments, rather than by incisor retraction.
PATIENTS AND METHODS

The present study employed the pretreatment and posttreatment records of 42

edgewise patients (20 male and 22 female) with Class II, Division 1 malocclusions
treated in conjunction with the extraction of maxillary first premolars at the
Department of Orthodontics, St. Louis University Medical Center. The average
starting age was 15.3 years (range, 8.7 to 39 years), and the average treatment
time was 19 months (range, 11 to 33 months). Selection was based solely on the
availability and adequacy of records and was in no way influenced by any measure
of treatment outcome (e.g., cooperation).
Cephalometric technique
The present analysis was designed to measure the individual anteroposterior dental
and skeletal changes that sum to produce the molar and overjet corrections (Fig. 1).
This general method has been described in detail elsewhere20,21 and uses Bjrk's
methods of cranial base, maxillary, and mandibular superimposition22-24 to
measure the movement of the buccal segments (measured at the mesial contact
points of the first molars) and the incisors relative to basal bone and the
displacement of the jaws relative to cranial base. These individual components of
the molar and overjet corrections are measured parallel to the mean functional
occlusal plane (MFOP; with the maxillae superimposed, the pretreatment and
posttreatment occlusal planes are averaged by inspection)25 and are given signs
appropriate to their contribution: positive if they reduce the overjet or normalize the
major occlusion; negative, if they make things worse. In this analysis, the
contribution from mandibular growth/advancement (Mand.) is assessed with
reference to D point, the center of the symphysis located by inspection on the initial
tracing and then passed through to the final tracing by regional superimposition.
Unfortunately, because of mandibular rotation, a change in the position of D point
parallel to the MFOP does not necessarily imply a like displacement at the head of
the condyle.
To generate a direct measure of condylar displacement during treatment, C point,
the center of the pretreatment condyle (and thus presumably a landmark in "basal"
bone), and condylion (Co), the most posterosuperior point on the surface of the
condyle were passed through to the posttreatment mandibular tracing by regional
superimposition in the mandibular body (symphysis, molar germs) and condyle,
respectively. Their displacement during treatment was then assessed with reference
to a Cartesian coordinate system in which Frankfort Horizontal (FH;
pretreatment/posttreatment average) served as the abscissa, and a perpendicular
erected through SE point (the point at which the averaged outlines of the greater
wings cross the planum sphenoidale) formed the ordinate.
In addition, the extent to which the drift of surface landmarks produced an apparent
change in condylar position was assessed by measuring sella to articulare and sella
to condylion (S-Ar and S-Co). To generate individualized control data for the
behavior of these two measures, expected (i.e., mean) increments were calculated

for each subject by interpolation according to age, sex, and treatment time from the
Michigan cephalometric standards.26 To address the popular concept that premolar
extraction/incisor retraction routinely produces "dished-in" profiles,4 upper and
lower lip retraction was measured, both parallel to MFOP (maxillary superimposition)
and perpendicular to Ricketts' E plane. Finally, from the standpoint of a best-fit
cranial base superimposition, we measured change in the angulation of FH, the
mandibular plane, and arbitrary "basal" mandibular and maxillary planes defined by
pairs of fiducial landmarks established on the first tracing and then passed through
to the second by detailed maxillary and mandibular regional superimposition.
Statistical analysis
Common descriptive statistics (mean, standard deviation, range), as well as t
statistics for the null hypothesis of no change during treatment (Ho:d = 0), were
calculated for all measures in the present analysis. In addition, paired t tests were
used to test the null-hypothesis that the changes in S-Ar and S-Co do not differ
significantly from the norms inferred from the Michigan standards.26 Productmoment coefficients of linear correlation (r) were calculated to estimate the
strength of the relationship between mandibular displacement, measured both at
the chin (D) and condyle (C), and changes in tooth position the maxillary molars
and the incisors, each measured relative both to maxillary basal bone (U1 and U6)
and to cranial base (U1 plus Max. and U6 plus Max.).
Finally, because one-arch treatments encourage the mandible to settle back into a
fully interdigitated Class II molar relationship, there obviously can be changes in
mandibular position that are independent of tooth movement. As a result, partial
correlation (rxy.z) was used to examine the relationship between mandibular
displacement and the movement of the molars and the incisors, with change in
molar relation (6/6) held constant.
RESULTS
Descriptive statistics for the various dental and skeletal components of the molar
and overjet changes, along with t scores testing the null hypothesis of no change,
are summarized in Table I. It may be noted that, except for apical base change
(ABCH), all dimensions changed significantly during the course of treatment; D point
showed a forward displacement that averaged 1.2 mm. For both the molar and the
ovejet corrections, tooth movement was by far the most important component.
Descriptive and inferential statistics for lip retraction, measures of mandibular
displacement taken at the condyle, and angular measures of facial divergence are
presented in Tables II and III.
Although our estimates of the change in the position of condylar basal bone
(horizontal change in C point) suggest that it, too, is usually displaced anteriorly, a
surface landmark (Co) tends to maintain its horizontal position or even move
distally (see S-Co and S-Ar). The distal drift of the condylar surface implied by the

significant increase in S-Co and S-Ar, however, does not differ significantly (i.e., P <
0.05) from the individualized norms for these measures inferred from the Michigan
standards for untreated persons: t = 0.90 and 1.86, respectively. Note also that the
marked retraction of the upper incisors did not have a comparable impact on the
lips. More to the point of this communication, the incisor changes were essentially
unrelated to condylar displacement during treatment.
From the correlation coefficients summarized in Table IV, it may be seen that
anteroposterior change in the position of the chin (D point) was related to two of the
measures of incisor displacement relative to cranial base and to all four measures of
change in upper molar position. In contrast, the displacement of condylar basal
bone (C point) was related only to changes in the position of the maxillary molars.
DISCUSSION
From the present data, it is clear that the majority of maxillary first-premolarextraction patients undergo a mesial mandibular displacement (along with a slight
opening rotation) during maxillary premolar-extraction treatment. Regardless of
whether displacement of C point, D point, or the mean of the two serves as the
criterion, only about 30% (13 of 42) of the present subjects gave evidence of any
posterior shift (an average of 1 to 2 mm distal for this small subsample). Moreover,
from the correlation coefficients of Table IV, it is clear that variation in mandibular
position was correlated not with incisor retraction, but, rather, with displacement of
the buccal segments. Indeed, the coefficients of linear correlation for the
relationship between mandibular displacement (measured both at condyle and at
the symphysis) and changes in the position of the maxillary buccal segments were
exceptionally high (up to 0.9). Although movement of D point bore a statistically
significant relationship both to molar movement and to incisor retraction, condylar
displacement was correlated only with changes in the position of the molars and
premolars. On the face of it, the present modest correlation between incisor
retraction and symphyseal displacement would seem to support the functional
orthodontic hypothesis. It should be noted, however, that this relationship may
reflect the impact of a third factor, the buccal segment changes and mandibular
rotation that would of necessity precede or accompany varying degrees of incisor
retraction. For example, greater-than-average incisor retraction might require
extensive use of Class II elastics and headgear, both of which would tend to reduce
maxillary anchorage loss, to increase mandibular anchorage loss, and to extrude
the molars. In the present analysis, the resulting downward and backward rotation
would be read as a posterior displacement of the chin, and the buccal segment
changes, the only effects that actually correlated with condylar displacement, would
at the same time tend to produce a posterior bodily displacement of mandibular
basal bone. In any event, if the direction of displacement is related to the molars,
rather than the incisors, a post hoc analysis should support this interpretation.

For purposes of discussion, the present sample was subdivided according to the
direction of mandibular displacement (based on the algebraic average of the C and
D point displacement), and the various skeletal and dental components of the molar
and overjet corrections contrasted by means of completely randomized t tests. It
may be seen from the "pitchfork" diagrams of Fig. 2 that the two subgroups did not
differ significantly in terms of incisor retraction. Instead, the patients whose
mandibles appear to have been displaced distally were those whose maxillae
showed little forward growth (including every patient who was 17 years or older at
the outset) and/or who either lost less anchorage than average in the maxilla or
more anchorage than average in the mandible. Once again, the present findings
support the logically (and biologically) more compelling alternative hypothesis that
change in the centric occlusal position of the mandible is a function of changes in
anteroposterior position of the occluding buccal segments, rather than the generally
nonoccluding incisors. As noted in a recent review by Tallents and coworkers19:
To make an assumption that the condyle has been forced distally as a result of
therapy, without appropriate pretreatment documentation, is untenable. To make
the assumption that because the incisors are upright they are "over-retracted," and
that this over-retraction produced changes in condyle position again is untenable
without adequate pretreatment documentation.
Unfortunately, the present data argue that "adequate documentation" may be
difficult to come by. In contrast to the significant mesial displacement of condylar
"basal" bone, the surface of the condyle (abstracted here by Co) tended to remain
stationary or even drift posteriorly a few tenths of a millimeter, a change that is
consistent with the normal, growth-related posterior movement of the glenoid fossa
(S-Ar; S-Co). Presumably, this relative stability is a by-product of the same condylar
adaptability that underwrites the action of contemporary functional appliances.27
Moreover, it has recently been reported that the radiographic outline of the condyle
may be subject to "seasonal variation."28 Thus, if surface changes tend not only to
produce cyclic modifications in the apparent form of the condyle, but also to mask
the true nature of any bodily displacement, then it would seem a futile gesture to
use any kind of conventional condylar radiograph to assess changes in condylar
position in unimplanted, growing patients.
Thus the present findings seem to support Wyatt'S scheme for iatrogenic
mandibular distal displacement: "As the maxilla [sic] is moved backward, the
muscles of mastication will attempt to retract the mandible when the patient closes
in to [sic] maximum intercuspation."5 It seems appropriate, therefore, to note that if
distal displacement actually does cause CMD, only patients who show a ponderable
distal displacement of the upper buccal segments would be at risk. Thus the
functional orthodontists should denounce nonextraction treatments and instead
embrace premolar extraction, because in the former the maxillary buccal segments
are commonly moved distally, whereas in the latter they almost always come
forward as the extraction sites are closed.20,21 Indeed, in the present study, 41 of

42 subjects showed mesial movement of the upper buccal segments. This

argument, of course, is advanced mostly out of exasperation, because in truth any
treatment can probably be modified to minimize displacement in any direction or
misused to maximize it. It remains to be seen, however, whether a millimeter or so
of mandibular displacement is actually' a threat to the public health. If the refereed
literature is any guide, there is precious little, if anything, in the way of support for
this contention.19,29-30 Moreover, one must consider the ultimate fate of changes
in mandibular position caused by orthodontic tooth movement.
Given the unremarkable assumption that centric occlusion is determined by teeth, it
should come as no surprise that orthodontic treatment can change the position of
centric occlusion. But what happens to this treatment-induced mandibular
displacement once the appliances are removed? Although the present data do not
address this issue, it may be noted that, in the absence of appliances, it is usually
thought that the jaws move the teeth as part of the process of dentoalveolar
compensation.31 For example, it is usual to interpret the crowded, retroclined lower
incisors of the patient with a Class III malocclusion as a dentoalveolar compensation
for a pattern of mandibular overgrowth. Accordingly, few would say that the excess
growth results from the mandible being "freed up" by the linguoverted incisors,
because to do so would be to reverse our usual ideas of cause and effect. And yet in
the next breath we are often quite willing to talk of "trapped" mandibles in Class II,
Division 2 malocclusions or to express concern that tooth movement might produce
a permanent distal or, if you are gnathologically oriented, mesial displacement
of the mandible. In other words, we fear that, even after appliances have been
removed, the teeth are more likely to displace the jaws than they are to move
through bone. The transience of both the posterior mandibular positions produced in
so-called "centric relation" reconstructions32 and the anterior displacement
commonly produced by comprehensive orthodontic treatment17 argues that the
jaws will ultimately win out over the teeth.
Despite marked maxillary incisor retraction measured parallel to MFOP, the upper
lip, on average, showed only a little over a millimeter of change; the lower lip, none.
Both lips, however, showed a more pronounced retraction relative to E plane. Thus
the present data imply that the normal growth of the nose and chin may have a
more profound long-term impact on the relative protrusion of the lips than does the
orthodontic retraction of the incisors. This interpretation does not mean that
treatment never produces marked lip retraction (one patient, for example,
experienced about 6 mm of upper lip retraction along MFOP); rather, it argues that
the soft tissue changes produced by onearch extraction treatments are, on average,
much less pronounced than we have been led to expect, a conclusion that echoes
the sentiments of a recent examination of four first-premolar-extraction
treatments.33

On balance, our data argue that the corpus of "functional orthodontic" thought
concerning the evils of premolar extraction is either dead wrong or grossly
exaggerated; if adhered to, it may constitute a threat to the public health.
SUMMARY
Regional cephalometric superimposition was employed to characterize the dental
and skeletal changes seen in a sample of 42 patients who had Class II, Division 1,
maxillary first-premolar extraction and who were treated with the edgewise
technique. Approximately 70% of the present sample underwent varying degrees of
forward mandibular displacement; 30% of the sample underwent distal. More
significantly, this mandibular displacement was correlated not with maxillary incisor
retraction, which averaged 5 mm, but rather with changes in the spatial position of
the buccal occlusion. Surface changes, however, apparently tended to keep the
head of the condyle fixed in space, regardless of the direction of basal displacement
produced by treatment. Finally, although the present treatments produced marked
incisor retraction, the soft tissue profile appears to have been influenced more
profoundly by the growth of the nose and chin. Thus the present data fail to support
the claim that premolar extraction and incisor retraction must, of necessity, lead to
unsightly profiles and distal mandibular displacement.
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