Janson et al.

Progress in Orthodontics 2014, 15:51

http://www.progressinorthodontics.com/content/15/1/51

RESEARCH Open Access

Frequency evaluation of different extraction

protocols in orthodontic treatment during
35 years
Guilherme Janson*, Fábio Rogério Torres Maria and Roberto Bombonatti

Abstract
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.
Keywords: Orthodontic treatment; Frequency of treatment protocols; Extraction vs non-extraction

Background an actual and accessible alternative therapy also seems to

The decision to extract teeth or not and the number of be susceptible to moments of transition.
teeth to be extracted can influence the final result of Retrospective studies [3-8] of extraction frequencies in
orthodontic treatment, including esthetics, occlusion, sat- orthodontic treatments are quite scarce and usually reflect
isfaction of patients and their families, as well as the treat- the reality of North America or Europe. In this way, it
ment time [1,2]. For many years the extraction decision would be interesting to verify if the extraction frequencies
has instigated much discussion and controversies, often in other parts of the world are different from these places.
linked to personal preferences than scientific criteria [3]. Therefore, the purpose of this retrospective study was to
In the last decades, Orthodontics has experienced concep- evaluate the frequency of the different treatment protocols
tual and technological changes influenced by dominant at the Orthodontic Department of Bauru Dental School,
trends in each time. Extraction orthodontic treatment, as University of São Paulo, Brazil, during the last 35 years.

* Correspondence: [email protected]
Department of Orthodontics, Bauru Dental School, University of São Paulo,
Alameda Octávio Pinheiro Brisolla 9-75, Bauru, SP 17012-901, Brazil

© 2014 Janson et al.; licensee Springer. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
Janson et al. Progress in Orthodontics 2014, 15:51 Page 2 of 7
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Methods quantified. After 3 weeks, 30 patients were randomly se-

The data was retrospectively obtained from 3,745 consecu- lected, and their treatment protocols were re-evaluated by
tively treated patients from the files of the Orthodontic the same examiner to verify the intraexaminer error.
Department at Bauru Dental School, University of São The study protocol was approved by the Ethics Com-
Paulo, from 1973 to 2007. Patient files (records, extra- mittee on Human Research of Bauru Dental School,
oral, and intraoral photographs, radiographs and study University of São Paulo.
models) were sequentially evaluated and 332 (8.86%)
were excluded, resulting in 3,413 cases in the sample. Statistical analysis
Exclusion criteria were patient transfer or treatment The frequencies of each protocol were compared among
drop out, preventive and orthopedic treatment without the intervals with the proportion test [9]. Results were
following orthodontic treatment with fixed appliances considered significant at P < 0.05. These analyses were
and cases without complete records. performed with Statistica software (Statistica for Windows
The sample consisted of 1,475 males (43.21%) and 1,938 version 7.0, Statsoft, Tulsa, Okla.).
females (56.79%) treated with an initial mean age of
13.76 years (SD ± 3.65; range 5.20 to 49.00 years), divided Results
according to the treatment protocol: Protocol 0 (non- All 30 re-evaluated patient records presented complete
extraction); Protocol 1 (four first premolar extractions); agreement with the first observation, confirming the
Protocol 2 (two maxillary first and two mandibular second high reproducibility of the methodology. Figure 1 shows
premolar or a variation to three first premolar and one the frequency increase of non-extraction treatments and
mandibular second premolar extractions); Protocol 3 (two the reduction in the number of extraction treatments
maxillary premolar extractions); Protocol 4 (four second and four premolar extraction protocol in all evaluated
premolar or a variation to three second premolar and one intervals. Some protocol frequencies were significantly
mandibular first premolar extractions); Protocol 5 (asym- different among the seven intervals (Table 1). The two-
metric extractions - three premolars or only one pre- phase treatments and the occurrence of re-planned case
molar); Protocol 6 (incisor or canine extractions); Protocol frequencies comparison are presented in Table 2.
7 (first or second molar extractions); Protocol 8 (atypical
extractions) and Protocol 9 (patients with agenesis or pre- Discussion
viously missing permanent teeth). The frequency of these Because the sample consisted of all treated patients in
protocols were evaluated in seven 5-year intervals similar the Orthodontic Department at Bauru Dental School,
to Profitt [8]: Interval 1 (1973 to 1977); Interval 2 (1978 to from 1973 to 2007, it would not be necessary to apply
1982); Interval 3 (1983 to 1987); Interval 4 (1988 to 1992); inferential statistical tests. Even though, to provide more
Interval 5 (1993 to 1997); Interval 6 (1998 to 2002); and mathematical precision, the Proportion Test was used to
Interval 7 (2003 to 2007). The frequency of each protocol evaluate whether there was any significant difference in
was compared among the seven intervals in order to iden- the treatment protocol frequencies between each time
tify some predominant trends at each tested period. One- interval. This type of frequency distribution test is
phase and two-phase treatments and re-planned cases that strongly influenced by the number of events observed.
included extractions in the new planning were also This explains why, in Table 1, the frequency of protocol

Figure 1 Frequency of extraction and non-extraction treatment and premolar extraction protocol in all evaluated intervals.
 http://www.progressinorthodontics.com/content/15/1/51
Janson et al. Progress in Orthodontics 2014, 15:51
Table 1 Frequency of 10 treatment protocols in all evaluated intervals (proportion test)
Protocol Total
0 1 2 3 4 5 6 7 8 9
Two maxillary first Agenesis or
Asymmetric
Interval Four first and two Two maxillary Four second Incisor or First or previously
Non- extractions - three Atypical
premolar mandibular second premolar premolar canine second molar missing N %
extraction premolars or only extractions
extractions premolar extractions extractions extractions extractions permanent
one premolar
extractions teeth
N % N % N % N % N % N % N % N % N % N %
1 A A ABC BC BC ABC
15 57 11 6 1 1 0 0 0 0 2 1.90 12 11.43 105 3.08
(1973 to 1977) 14.29 54.29 10.48 5.71 0.95 0.95
2 AB A CD AB BC AB
28 84 5 5 2 1 0 0 0 0 2 1.37 19 13.01 146 4.28
(1978 to 1982) 19.18 57.53 3.42 3.42 1.37 0.68
3 B B A BC CD A
91 90 40 34 11 4 1 0.32 3 0.96 14 4.46 26 8.28 314 9.20
(1983 to 1987) 28.98 28.66 12.74 10.83 3.50 1.27
4 CD B BC BC BC A
273 170 34 62 7 13 2 0.30 7 1.05 23 3.45 75 11.26 666 19.51
(1988 to 1992) 40.99 25.53 5.11 9.31 1.05 1.95
5 C B BC CD BC BC
491 281 63 137 13 61 6 0.48 10 0.79 61 4.83 139 11.01 1262 36.98
(1993 to 1997) 38.91 22.27 4.99 10.8 1.03 4.83
6 DE C BCD CD AB C
290 95 25 67 2 44 1 0.16 6 0.98 19 3.10 63 10.29 612 17.93
(1998 to 2002) 47.39 15.52 4.08 10.95 0.33 7.19
7 E D D BC BC C
168 23 4 23 6 21 0 0 2 0.65 10 3.25 51 16.56 308 9.02
(2003 to 2007) 54.55 7.47 1.30 7.47 1.95 6.82
Total 1,356 39.73 800 23.43 182 5.3 334 9.78 42 1.23 145 4.24 10 0.29 28 0.82 131 3.83 385 11.28 3,413 100
χ 113.305 222.758 52.847 13.668 19.443 41.901 3.440 2.897 8.640 12.522
P 0.0000* 0.0000* 0.0000* 0.0335* 0.0034* 0.0000* 0.7518 0.8215 0.1948 0.0512
Different letters represent statistically significant differences in same protocol. *Statistically significant at P < 0.05.

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Table 2 Frequency of one-phase and two-phase treatments and re-planned cases in all evaluated intervals
(proportion test)
One-phase Two-phase Not replanned Re-planned
Interval N
N % N % N % N %
1
105 104 99.05 1 0.95A 104 99.05 1 0.95BC
(1973 to 1977)
2
146 145 99.32 1 0.68A 143 97.94 3 2.06BC
(1978 to 1982)
3
314 309 98.73 5 1.27A 305 97.13 9 2.87BC
(1983 to 1987)
4
666 636 98.05 30 1.95AB 653 98.05 13 1.95BC
(1988 to 1992)
5
1262 1172 95.17 90 4.83BC 1226 97.15 36 2.85BC
(1993 to 1997)
6
612 521 92.81 91 7.19D 587 95.91 25 4.09AB
(1998 to 2002)
7
308 296 93.18 12 6.82AB 306 99.35 2 0.65CD
(2003 to 2007)
Total 3,413 3,183 93.26 230 6.74 3324 97.39 89 2.61
χ 101.272 12.726
P 0.0000* 0.0475*
Different letters in two-phase treatment or in re-planned cases represent statistically significant differences. *Statistically significant at P < 0.05.

5 in interval 7 (6.82%) is statistically different from recently, there are reports about treatment difficulty [27],
interval 3 (1.27%), but not different from interval 1 greater treatment time [28], and risks of root resorption
(0.95%). and periodontal problems [29], especially in adult patients.
In this study, the treatment protocols with (Protocols Investigations indicate that dental extractions tend to pro-
1 to 9) and without extractions (Protocol 0) showed long treatment time, in general [30,31].
great statistically significant variation among the consid- In this study, the frequency of treatments with four
ered intervals (Figure 1 and Table 1). In the first interval, first premolar extractions (Protocol 1) decreased sig-
1973 to 1977, 85.71% of cases were treated with some nificantly, corroborating the findings of other studies
type of extraction protocol, demonstrating the influence [3,6-8] (Table 1). The frequency of two maxillary first
of extraction dogmas at that time [10,11]. This tendency premolar and two mandibular second premolar extrac-
decreased, similar to other studies [6-8], until it reaches tion protocol (Protocol 2) also demonstrated statistically
a frequency of 45.45% of cases with extractions in the significant differences among the evaluated intervals
last interval 2003 to 2007. These findings clearly demon- (Table 1). This reduction, also observed by others re-
strate the great influence of extraction concepts on the searchers [6-8], appears to have been influenced by the
percentage of cases treated with extractions in the 1960s same historical reasons discussed for the four first pre-
and 1970s [10-13]. Since then, there has been a decrease molar extractions protocol.
of extraction treatment consequent to studies which The two maxillary premolar extraction protocol (Proto-
showed relapses even in these cases [14,15], the possibil- col 3) showed a relatively stable frequency around 10% in
ity of protruding the mandibular incisors in some situa- most of the evaluated periods (Table 1). This fact can be
tions [16,17], the belief that there could be a relationship interpreted as an increase in preference of this specific
between extractions and temporomandibular disorders protocol due to drastic reduction of extraction treatment
[18,19], and the possibility of treatments with interproxi- between 1973 and 2007 (Figure 1). In other investigations,
mal stripping [20,21]. Technical changes also may have frequencies ranged from 5% [5] to 22% [6]. Maxillary pre-
also influenced this decline, such as an increase in ortho- molar extractions seem to be very useful in Class II
pedic appliances usage [22], maxillary expanders [23], as malocclusion orthodontic treatment [18,28,32,33]. This treat-
well as treatment in two phases [24,25]. ment approach has a greater occlusal treatment success rate
The choice for four first premolars was for a long time compared to four premolar extractions [32] and presents
the classic extraction protocol [10,26]. However, more a shorter treatment time of complete Class II malocclusions
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[28]. This may minimize root resorption and iatrogenic Protocol 9 included all cases with previous dental ab-
effects, in addition to providing greater personal and fi- sences. It was considered that these patients should not
nancial benefits to patients [27,30]. be excluded from the study by the fact that similar cir-
The therapeutic choice of four second premolar extrac- cumstances happen in daily clinical routine, and should
tions (Protocol 4) demonstrated a much-reduced frequency be statistically described. They were placed in a separate
in all evaluated intervals (Table 1). Although it presents a group because their previous condition could have influ-
small frequency, this protocol is usually used when an- enced the treatment planning. The total mean frequency
chorage can be lost, producing smaller impact on the soft of these cases was 11.28%, and their frequencies in the
tissues or in cases with moderate crowding [34,35]. Four several periods showed no statistically significant differ-
premolar extractions frequency (Protocols 1, 2, and 4 to- ences (Table 1).
gether) decreased gradually from 65.72% (1973 to 1977) to Some authors suggest that a two-phase protocol in the
10.72% (2003 to 2007, Figure 1, Table 1). treatment of Class II malocclusion provides best thera-
The asymmetric extraction protocol of three premolars peutic results and greater stability [49,50]. However, this
(Protocol 5 - two maxillary and one mandibular premolar) claim is very controversial because the influence of the
is indicated in Type 1 Class II subdivision malocclusion orthopedic phase in the final clinical results is practically
treatment [36]. Asymmetric extraction treatment provides non-existent [51-55]. In this study, treatment was con-
an easier mechanics and better occlusal treatment success sidered to have been conducted in two phases when pa-
rate when compared to four premolar extractions [37] and tients had used only functional orthopedic appliances for
less mandibular incisor and soft tissue retraction [38]. A more than 6 months for Class II malocclusion correction
variation of asymmetric extraction therapy in Class II mal- [24,49,56,57]. The frequency of two-phase treatment was
occlusions may include only one premolar extraction [39]. of 6.74% and differed from other works that found a
In this study, the initial frequency of indications of three mean of 12% [7] and 20% [6]. Interval 6 (1998 to 2002)
premolar extractions was extremely low and increased to presented the highest frequency of two-phase treatment
7.19% between 1998 and 2002, when it was demonstrated that was statistically different from the other periods.
to provide a better occlusal success rate than four premolar This greater frequency was probably due to the possible
extractions in Class II subdivision malocclusions [37] benefits that orthopedic correction could provide in
(Table 1). While this frequency increased and remained Class II treatment, as was thought in the 1980s and
stable over the last two intervals, there was a drastic re- 1990s (Table 2). On the other hand, also in Interval 6,
duction of the frequency of indications of extractions as there was a higher incidence of re-planned cases includ-
a whole. Thus, similar to the protocol with two maxil- ing extractions, probably due to failures or lack of pa-
lary premolar extractions, there was an increase in the tient compliance in the initial non-extraction approach
use of this protocol. [30,58] (Table 2).
Protocols 6, 7, and 8 exhibited low frequencies with-
out significant differences among them (Table 1). These
findings seem to demonstrate certain stability of their Clinical implications
indications in the evaluated periods. Consequently, it is Studies that show frequencies of different orthodontic
speculated that these approaches are not susceptible to treatment protocols can be used as valuable parameters in
influences of prevalent philosophies. Mandibular inci- the interpretation of treatment tendency with time. In this
sor extraction frequencies were observed in the litera- way, the orthodontist can judge these tendencies and
ture to be around 1% [5], 2.1% [3], 2.2% [7], and 2.5% understand the actual reasons why accepted decisions
[6] and molar extractions, 3.0% [3]. Mandibular incisor have changed over years of orthodontic practice. Finally,
extraction should be considered in cases with tooth size these findings suggest the idea that modern orthodontist
discrepancy [40,41], although it may increase overbite should not hold on paradigms without questioning them.
and overjet [41,42]. It is also indicated when smaller pos- It is up to him to be always updated and not to rely in
terior teeth mesialization is needed, to shorten treatment dogmatic treatment approaches.
time, to produce smaller impact on the facial profile, for
Class III malocclusion treatment and in cases with some Conclusions
periodontal problems [42-44]. Maxillary second molar ex- The following conclusions are drawn from the study:
tractions can be a valuable therapeutic approach which
could lead to more stable results [45,46], facilitate first 1. The non-extraction protocol frequency increased
maxillary molar distalization, produce easier overbite gradually from 14.29% (1973 to 1977) to 54.55%
correction [41,47] and smaller impact on facial profile, (2003 to 2007), with consequent reduction of
and present a smaller percentage of extraction spaces extraction treatments from 85.71% (1973 to 1977)
re-openings [48]. to 45.45% (2003 to 2007).
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2. The four premolar extraction protocol frequency 17. Mills JR, Vig KW. An approach to appliance therapy–part II. Br J Orthod.
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Competing interests
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The authors declare that they have no competing interests.
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GJ developed the idea of the investigation, supervised all the research vestibular shields. Am J Orthod. 1974; 65(4):372–406.
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GJ is Professor of the Orthodontic Department at Bauru Dental School, 25. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N, Chadwick S, et al.
University of São Paulo, Brazil, and Member of the Royal College of Dentists Effectiveness of early orthodontic treatment with the Twin-block
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doi:10.1186/s40510-014-0051-z
Cite this article as: Janson et al.: Frequency evaluation of different
extraction protocols in orthodontic treatment during 35 years. Progress
in Orthodontics 2014 15:51.

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