ORIGINAL ARTICLE

Effects of premolar extractions on Bolton overall

ratios and tooth-size discrepancies in a Japanese
orthodontic population
Toshiya Endo,a Katuyuki Ishida,b Isao Shundo,b Kosuke Sakaeda,c and Shohachi Shimookad
Niigata and Kawasaki, Japan
Introduction: The purpose of this study was to investigate the effects of premolar extractions on the Bolton
overall ratios and overall tooth-size discrepancies in a Japanese orthodontic population. Methods: Mesiodistal tooth widths were measured on 198 pretreatment dental casts of subjects with Class I, Class II, and Class III
malocclusions. The overall ratios and tooth-size discrepancies were determined before and after hypothetical
premolar extractions. Before and after extractions, the subjects were divided into small, normal, and large
overall ratio groups categorized by the Bolton standard deviation definition, and into small, normal, and large
correction groups by the actual amount of change calculated for tooth-size correction in millimeters. Extractions were performed in the following combinations: (1) all first premolars, (2) all second premolars, (3) maxillary
first and mandibular second premolars, and (4) maxillary second and mandibular first premolars. For statistical
evaluations, analysis of variance, Kruskal-Wallis, Friedman, Scheffe, Bonferroni, and Tukey tests were performed. Results: The overall ratios decreased in every malocclusion group after extraction of any combination
of premolars. The decreases were significantly notable in combinations 2 and 4. Some subjects in the normal
overall ratio and maxillary and mandibular correction groups moved into the clinically significant tooth-size discrepancy group after premolar extraction, and the reverse was also true. Conclusions: In formulating a treatment plan involving premolar extractions, orthodontists should consider that the overall ratios might decrease,
and normal and clinically significant tooth-size discrepancies could change mutually after extractions. (Am J
Orthod Dentofacial Orthop 2010;137:508-14)

oltons tooth-size ratios, including overall and

anterior ratios, have been widely accepted as
an essential diagnostic tool in orthodontic practice since their publication.1,2 The Bolton anterior and
overall ratios were defined as the ratios of the mesiodistal widths between the 6 anterior mandibular teeth and
the 6 anterior maxillary teeth, and the mesiodistal
widths between the 12 mandibular teeth and the 12 maxillary teeth, respectively.1,2 Some evidence points to sex
and racial or ethnic differences in the tooth-size ratios.3,4 Some investigators reported statistically significant associations between tooth-size ratios and
a

Professor and chairman, Orthodontic Dentistry, Nippon Dental University

Niigata Hospital, Niigata, Japan.
b
Assistant professor, Orthodontic Dentistry, Nippon Dental University Niigata
Hospital, Niigata, Japan.
c
Private practice, Kawasaki, Japan.
d
Professor and chairman, Department of Pediatric Dentistry, Nippon Dental
University School of Life Dentistry at Niigata, Niigata, Japan.
The authors report no commercial, proprietary, or financial interest in the products or companies described in this article.
Reprint requests to: Toshiya Endo, Orthodontic Dentistry, Nippon Dental University Niigata Hospital, 1-8 Hamaura-cho, Niigata 951-8580 Japan; e-mail,
endoto@ngt.ndu.ac.jp.
Submitted, February 2008; revised and accepted, April 2008.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.04.026

508

malocclusion types.5,6 Others found no significant differences in either anterior or overall ratios in subjects
with different malocclusion.7-9
A tooth-size discrepancy between the maxillary and
mandibular arches is found by analyzing tooth-size ratios. Some studies found that ratios more than 2 SD
from Boltons mean of 91.3% indicated clinically significant overall tooth-size discrepancies.5-12 In orthodontic practice, the actual amount of discrepancy (in
millimeters) provides more useful information on the
required correction for clinically significant tooth-size
discrepancy than does the ratio as a percentage.9,13
Some investigators9,13,14 selected 1.5 mm as an appropriate threshold for clinical significance of discrepancy,
quoting Proffit and Ackerman15 that tooth-size discrepancies less than 1.5 mm were rarely significant.
In orthodontic treatment, tooth extraction is often
necessary to achieve the best possible esthetic and functional outcome for patients, and the extraction of 4 first
premolars is most common.16 The overall ratio and
tooth-size discrepancies are directly influenced by premolar extraction. Nonetheless, only a few investigations
have been conducted about the applicability of the overall ratio as a criterion, shown by the shortage of literature.2,17 Bolton2 found that the mean overall ratio was

Endo et al

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 137, Number 4

91.3% (SD, 1.91) in patients without a tooth-size discrepancy, and, after extraction of 4 premolars, the patients had a mean overall ratio of 88% (SD, 1). Tong
et al17 stated that the overall ratios after extraction of
all premolar combinations were smaller than those before extraction, and, in some of the patients, normal
and large overall ratios changed into small and normal
overall ratios, respectively, after extraction of premolars. The change of overall ratio groups was especially
noteworthy in combinations of all second premolars
and the maxillary second and mandibular first premolars. Saatci and Yukay18 and Gaidyte and Baubiniene19
investigated tooth-size discrepancies created by premolar extractions using the Bolton index, which is a positive value of either maxillary or mandibular corrections
required to give the Bolton mean overall ratio.
The purpose of this study was to investigate the effects of premolar extractions on the Bolton overall ratios
and tooth-size discrepancies in a Japanese orthodontic
population.

MATERIAL AND METHODS

A total of 198 Japanese subjects with various malocclusions were selected retrospectively from a list of orthodontic patients who had received treatment in our
clinics at the Nippon Dental University Niigata Hospital, Niigata, Japan. They included patients with Class
I, Class II, and Class III malocclusions and met the criteria for the dental casts as described below. The occlusion category, according to Angles classifications,
coincided with the skeletal category. Skeletal types
were assessed cephalometrically by the mean ANB angles (3.3 6 2.1 for males; 2.6 6 1.7 for females) 20:
Class I, from 1.2 to 5.4 for males and from 0.9 to 4.3
for females; Class II, .5.4 for males and .4.3 for
females; and Class III, \1.2 for males and \0.9 for
females. Each malocclusion group consisted of 33
male and 33 female subjects. The selection criteria of
the casts were (1) fully erupted permanent dentition
with only the third molars unerupted, (2) good-quality
pretreatment casts, (3) no tooth agenesis or extractions,
(4) no mesiodistal restorations or abrasion, and (5) no
tooth anomalies.
Digital calipers were used to measure the mesiodistal widths from first molar to first molar to the nearest
0.01 mm on each cast. The mesiodistal width of each
tooth was measured at the greatest distance between
the contact points on the proximal surfaces. All measurements were done by 1 investigator (I.K.). The overall ratios were calculated by using the method of
Bolton.1,2

509

Thirty pairs of dental casts were randomly selected

a month later, and the mesiodistal tooth widths were
again measured by the same investigator. The overall ratios were calculated by the same method. A paired t test
showed no statistically significant differences between
the first and second measurements (P .0.05). Random
errors, assessed by calculating the standard deviation of
the differences between the first and second measurements, were less than 0.72% for the overall ratios, and
less than 0.8 and 0.73 mm for the maxillary and mandibular corrections, respectively; these were unlikely to
affect the significant results in this study.13
Because 2-way analysis of variance (ANOVA) indicated no significant differences in overall ratios between
the sexes or malocclusion types, and no significant interaction between 2 variables, the values for the sexes were
combined for all other analyses, as shown in Tables I
and II.
In each malocclusion group, hypothetical tooth extractions were performed on each subject in the following 4 combinations: (1) all first premolars, (2) all second
premolars, (3) maxillary first and mandibular second
premolars, and (4) maxillary second and mandibular first
premolars. The overall ratios were again calculated after
the hypothetical extractions in each malocclusion group.
Calculations were made before extractions to determine the distributions of subjects with overall toothsize discrepancies more than 2 SD from the Bolton
means (91.3% 6 1.91%) and more than 1.5 mm of
maxillary or mandibular correction required to give
the Bolton mean overall ratio, and all the subjects
were subdivided into 3 groups in each category: (1)
small overall ratio (\87.48%), (2) normal overall ratio
(87.48% to 95.12%), and (3) large overall ratio
(.95.12%). Both maxillary and mandibular correction
groups were (1) small correction (\1.5 mm), (2) normal correction (1.5 to 11.5 mm), and (3) large correction (.1.5 mm).
Similarly, to determine how many subjects moved
into other groups, the number of subjects in each group
was calculated again according to the Bolton mean
overall ratio (88%; SD, 1)2 and a 1.5-mm threshold
after all premolar extraction combinations.
Statistical analysis

Statistical analyses were performed with StatMate

software (ATMS, Tokyo, Japan). The means and standard
deviations of the overall ratios were calculated before and
after the 4 extraction combinations of premolars in each
malocclusion group. Two-way ANOVA was performed
to test the main effects of extractions and malocclusion
types on the overall ratio. One-way ANOVA and Scheffe

510

Endo et al

Table I.

American Journal of Orthodontics and Dentofacial Orthopedics

April 2010

Overall ratios (mean 6 SD) before and after extractions in each malocclusion group and statistical compar-

isons
Before extraction (BE)
Group

Male

Female

Scheffe

After extraction

Both sexes

4/4

5/5

4/5

5/4

Significance

Class I
91.18 6 2.27 91.01 6 2.17 91.10 6 2.20 89.74 6 2.41 88.89 6 2.11 90.04 6 2.37 88.61 6 2.24 BE . 5/5, BE . 5/4
malocclusion
Class II
91.48 6 1.91 91.28 6 1.87 91.38 6 1.88 89.91 6 2.00 89.00 6 1.73 90.07 6 1.84 88.86 6 1.93 BE . 4/4, BE . 5/5,
malocclusion
BE . 4/5, BE . 5/4
Class III
91.27 6 1.56 91.85 6 2.16 91.56 6 1.89 90.27 6 1.98 89.24 6 1.89 90.47 6 1.99 89.05 6 1.96 BE . 5/5, BE . 5/4,
malocclusion
4/5 . 5/4
4/4, All first premolars; 5/5, all second premolars; 4/5, maxillary first and mandibular second premolars; 5/4, maxillary second and mandibular first
premolars.

Two-way ANOVA of overall ratios before

extractions as a function of sex and malocclusion type

Table III.

Source

Source

Table II.

Sex
Malocclusion
type
Interaction
Error

Sum of squares

df

Mean square F value P value

0.231
7.154

1
2

0.231
3.577

0.057
0.890

0.811
0.412

6.492
771.615

2
192

3.246
4.019

0.808

0.447

tests were used to compare the overall ratios before and

after extractions in each malocclusion group and to identify where differences occurred. Kruskal-Wallis and
Bonferroni tests, and Friedman and Tukey tests, were performed to determine whether and where there were
changes in the numbers of subjects and the distributions
of overall ratios, respectively, in each overall ratio group
and in each maxillary and mandibular correction group
related to the extraction combinations. ANOVA and multiple comparison tests were performed at the P \0.05
level of significance.

RESULTS

Table III shows that 2-way ANOVA indicated no

significant interaction between the main effects of extractions and malocclusion types and no significant differences in the overall ratios between the malocclusion
types. It also shows significant difference in the overall
ratios between before and after extractions. Table I
shows that the overall ratios decreased in every malocclusion group after extraction of any combination of
premolars, and that the statistically significant decreases were particularly notable in combinations 2
and 4.
Two-way ANOVA, performed to test the main effects of sex and malocclusion types on the overall ratios,
indicated no significant differences between malocclu-

Two-way ANOVA of overall ratios as a function of extraction and malocclusion type

Extraction
Malocclusion
type
Interaction
Error

Sum of squares

df

Mean square F value P value

799.355
33.101

4
2

199.839
16.551

549.901
0.857

0.000
0.426

2.183
283.459

8
780

0.273
0.363

0.751

0.646

sion types (Table II). Kruskal-Wallis tests showed no

significant differences between the malocclusion
groups in the distributions of subjects in the normal
overall ratio group and those of the clinically significant
overall tooth-size discrepancy group before extractions
(P 5 0.270, Table IV) or in the distributions of subjects
of the maxillary and mandibular correction groups (P 5
0.286 and P 5 0.365, respectively, Table V). Therefore,
the subjects of each malocclusion group were combined
in each category for other analyses.
Table VI shows that some subjects in the small overall ratio group moved into the normal overall ratio group
after 3 of 4 premolar extraction combinations, some
subjects in the normal overall ratio group moved into
the small or large overall ratio groups, and all subjects
in the large overall ratio group remained in the same
group after any premolar extraction combination. Moreover, Table VI shows that, in the normal overall ratio
group, Kruskal-Wallis and Bonferroni tests, and
Friedman and Tukey tests demonstrated significant differences in the distribution of subjects with overall
tooth-size discrepancies and in the overall ratios,
respectively, between the 2 extraction combinations
including maxillary second premolars and those including maxillary first premolars. This table also shows that,
in the large overall ratio group, there was a significant
difference in the distribution of overall ratios between
extraction combinations 3 and 4.

Endo et al

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 137, Number 4

Table IV.

511

Distribution of subjects of overall ratio groups before extraction

Overall ratio group
Normal group

Group
Class I malocclusion
Class II malocclusion
Class III malocclusion
Total malocclusion

Combined small and large groups

Kruskal-Wallis

P value

59
63
63
185

89.39
95.45
95.45
93.43

7 (4, 3)
3 (2, 1)
3 (2, 1)
13 (8, 5)

10.61 (6.06, 4.55)

4.55 (3.03, 1.52)
4.55 (3.03, 1.52)
6.57 (4.04, 2.53)

0.270

Small and large overall ratio groups, respectively, in parentheses.

Table V.

Distribution of subjects of maxillary and mandibular correction groups before extraction

Small

Group
Maxillary correction
Class I malocclusion
Class II malocclusion
Class III malocclusion
Total malocclusion
Mandibular correction
Class I malocclusion
Class II malocclusion
Class III malocclusion
Total malocclusion

Normal

Large

Kruskal-Wallis

20
12
10
42

30.30
18.18
15.15
21.21

32
38
41
111

48.48
57.58
62.12
56.06

14
16
15
45

21.21
24.24
22.73
22.73

14
14
12
40

21.21
21.21
18.18
20.20

32
41
45
118

48.48
62.12
68.18
59.60

20
11
9
40

30.30
16.67
13.64
20.20

Table VII shows that some subjects in the small and

normal maxillary correction groups moved into the normal and large maxillary correction groups, respectively,
and that all or almost all subjects in the large maxillary
correction group remained in the same group with the 4
extraction combinations. Table VIII shows that all or almost all subjects in the small mandibular correction
group remained as they were with any extraction combination, but some subjects in the normal and large mandibular correction groups moved into the small and
normal groups, respectively.
Tables VII and VIII show that, in the normal maxillary and mandibular correction groups, KruskalWallis and Bonferroni tests found significant differences in the distributions of subjects with maxillary
and mandibular corrections, respectively, between the
2 extraction combinations including maxillary second
premolars and maxillary first premolars. The tables
also show that, in the small maxillary correction and
large mandibular correction groups, significant differences in the distributions of subjects with maxillary
and mandibular corrections were found among different extraction combinations: between combinations 1
and 4, combinations 2 and 3, and combinations 3
and 4.

P value

0.286

0.365

Tables VII and VIII also show that in each maxillary

and mandibular correction group, Friedman and Tukey
tests demonstrated significant differences in the distributions of maxillary and mandibular corrections
between the 2 extraction combinations including maxillary second premolars and maxillary first premolars.
DISCUSSION

Some evidence reflects that various tooth-size ratios

show ethnic or racial and sex differences.5,6 Our
PubMed search in March 2008 with the search subjects
tooth size ratio and tooth size discrepancy found
no English references regarding the association between
Bolton overall ratio and extraction in a Japanese population. It would, therefore, be worthwhile to examine the
effects of premolar extractions on Bolton overall ratios
and tooth-size discrepancies in Japanese people and to
compare our results with those in other populations.
Our results showing no statistically significant differences between the sexes in the overall ratio for the malocclusion groups agreed with those of previous studies
on other populations.5,8,13 Some other investigations
showed statistically significant differences between
the sexes in the overall ratio for the malocclusion groups

512

Endo et al

Table VI.

American Journal of Orthodontics and Dentofacial Orthopedics

April 2010

Distribution of subjects of each overall ratio group after extractions and statistical comparisons
Overall ratio groups
Small

Before extraction
After extraction

Before extraction
After extraction

Before extraction
After extraction

4/4
5/5
4/5
5/4
4/4
5/5
4/5
5/4
4/4
5/5
4/5
5/4

Normal

8
5
7
4
8

3
8
1
16

0
0
0
0

100.00
62.50
87.50
50.00
100.00

1.62
4.32
0.54
8.65

0.00
0.00
0.00
0.00

3
1
4
0
185
90
125
76
118

0
0
0
0

Large

Kruskal-Wallis

Bonferroni

Friedman

Tukey

P value

Significant
comparison

P value

Significant
comparison

0.00
0.00
0.00
0.00

49.73
28.11
58.38
27.57
100.00
100.00
100.00
100.00
100.00

37.50
0
12.50
0
50.00
0
0.00
0
100.00
48.65 92
67.57 52
41.08 108
63.78 51

5
0.00
5
0.00
5
0.00
5
0.00
5

0.091

\0.001

0.273

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

\0.001

0.017

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

4/5 vs 5/4

4/4, All first premolars; 5/5, all second premolars; 4/5, maxillary first and mandibular second premolars; 5/4, maxillary second and mandibular first
premolars.
Table VII.

Distribution of subjects of each maxillary correction group after extractions and statistical comparisons
Maxillary correction groups
Small
n

Before extraction
After extraction
4/4
5/5
4/5
5/4
Before extraction
After extraction
4/4
5/5
4/5
5/4
Before extraction
After extraction
4/4
5/5
4/5
5/4

Normal
n

Large
n

Kruskal-Wallis

Bonferroni

Friedman

Tukey

P value

Significant comparison

P value

Significant comparison

4/4 vs 5/4

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

42 100.00

13 30.95 29
69.05 0
0.00
19 45.24 23
54.76 0
0.00
8 19.05 33
78.57 1
2.38
27 64.29 15
35.71 0
0.00

111 100.00

0
0.00 34
30.63 77 69.37
0
0.00 73
65.77 38 34.23
1
0.90 27
24.32 83 74.77
0
0.00 82
73.87 29 26.13

45 100.00
0
0.00 0
0.00 45 100.00
0
0.00 1
2.22 44 97.78
0
0.00 0
0.00 45 100.00
0
0.00 2
4.44 43 95.56

\0.001

\0.001

0.295

4/5 vs 5/4

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

\0.001

\0.001

\0.001

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

4/4, All first premolars; 5/5, all second premolars; 4/5, maxillary first and mandibular second premolars; 5/4, maxillary second and mandibular first
premolars.

among different populations.4,14,17 This permitted our

speculation that sex differences in tooth-size ratios
might be population-specific.
In this study, 2-way ANOVA showed no significant
differences in the overall ratios between the malocclusion groups, but significant differences before and after
extractions (Table III). Our result that the overall ratios
decreased after extraction of any combination of premolars in each malocclusion group was confirmed by Tong

et al.17 One-way ANOVA and Scheffe tests showed that

the extraction combinations with the most commonly
decreasing overall ratios in every malocclusion group
were 2 and 4; this also corresponded to the results of
the Friedman and Tukey tests: that significant differences in the distribution of overall ratios between extraction combinations 1 and 3 and combinations 2 and 4 were
found in the normal overall ratio group including most
subjects (Table VI). These findings show that the

Endo et al

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 137, Number 4

Table VIII.

513

Distribution of subjects of each mandibular correction group after extractions and statistical comparisons
Mandibular correction groups
Small
n

Before extraction
After extraction 4/4
5/5
4/5
5/4
Before extraction
After extraction 4/4
5/5
4/5
5/4
Before extraction
After extraction 4/4
5/5
4/5
5/4

Normal
n

Large
n

Kruskal-Wallis

Bonferroni

Friedman

Tukey

P value

Significant comparison

P value

Significant comparison

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

40 100.00

40 100.00 0
0.00 0
0.00
38 95.00 2
5.00 0
0.00
40 100.00 0
0.00 0
0.00
37 92.50 3
7.50 0
0.00

118 100.00

70 59.32 48
40.68 0
0.00
28 23.73 90
76.27 0
0.00
79 66.95 39
33.05 0
0.00
23 19.49 95
80.51 0
0.00

40 100.00
0
0.00 30
75.00 10 25.00
0
0.00 22
55.00 18 45.00
1
2.50 34
85.00 5
12.50
0
0.00 14
35.00 26 65.00

\0.001

0.136

\0.001

\0.001

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

4/4 vs 5/4
5/5 vs 4/5
4/5 vs 5/4

\0.001

\0.001

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

4/4 vs 5/5, 4/4 vs 5/4

5/5 vs 4/5
4/5 vs 5/4

4/4, All first premolars; 5/5, all second premolars; 4/5, maxillary first and mandibular second premolars; 5/4, maxillary second and mandibular first
premolars.

extraction of all second premolars and maxillary second

and mandibular first premolars most affect the overall ratios in orthodontic treatment involving premolar extractions. However, the mean overall ratios in the Class I and
Class II malocclusion groups ranged from 87% to 89%
after these 2 extraction combinations, as shown in Table
I. Orthodontic patients with Class I and Class II malocclusions treated with these 2 extraction combinations
of premolars might attain proper occlusal intercuspation.
Bolton2 stated that, after 4 premolar extractions, subjects
without a tooth-size discrepancy would have overall ratios of 87% to 89%. The decrease in the overall ratio in
any extraction combinations might be because the ratios
of the mesiodistal widths of the maxillary first or second
premolars to those of the 12 maxillary teeth (15.4% or
14.3%, respectively) were smaller than those of the mandibular first or second premolars to the 12 mandibular
teeth (16.7% or 16.5%, respectively) in this study. In
other words, in spite of first or second premolar extractions, the rates of the sum of the mesiodistal widths of
the remaining 10 teeth to the sum of those of the 12 teeth
are smaller in the mandible than in the maxilla.
A tooth-size discrepancy can affect orthodontic
treatment outcome and its stability. The mean overall ratios in every malocclusion group were more than 89%
after extraction combinations 1 and 3, demonstrating
that, if the sum of the mesiodistal widths of the remaining 10 teeth in the maxilla were considered normal, that
in the mandible would be greater than the mean. From
a clinical perspective, this finding suggests that the mandibular incisors need to be retroclined to achieve an

excellent Class I occlusion without interproximal

enamel reduction and that the first molar relationships
need to be in Class II occlusion for an ideal occlusion
of the incisors. Moreover, it suggests that selective interproximal enamel reduction might be required in the
mandibular teeth for proper occlusal interdigitation.
In this study, ratios greater than 2 SD from the Bolton
mean and discrepancies greater than 1.5 mm of the maxillary and mandibular corrections for overall ratios were
defined as indicating clinically significant tooth-size discrepancies. Our findings showed that the prevalence rate
of subjects with clinically significant tooth-size discrepancies before extraction by using the Bolton standard-deviation definition (6.57%, Table IV) was lower than those
with the millimetric definition as shown in the distribution
of subjects with maxillary and mandibular corrections
(43.94% and 40.4%, respectively, Table V). In our study,
significant differences in the distribution of maxillary and
mandibular corrections were found in 4 extraction combinations of any correction groups, whereas significant differences in the distribution of overall ratios were found in
4 combinations and 1 combination of the normal and large
overall ratio groups, respectively. These findings supported those of some investigators who demonstrated
that the use of millimetric measurements in the correction
of tooth-size ratios could prevent clinicians from underestimating the prevalence of clinically significant tooth-size
discrepancies.9,13,14
Our findings showed that some subjects in the small
overall ratio group moved into the normal group, and
some subjects in the normal overall ratio group moved

514

Endo et al

into either the small or large group, but all subjects in the
large overall ratio group stayed there after premolar extractions. These findings were inconsistent with those
by Tong et al,17 who found that all the subjects in the small
overall ratio group remained in this group, but some subjects in the normal and large overall ratio groups moved
into the small and normal groups, respectively. This inconsistency might be explained by the difference in the
Bolton mean used as a criterion after extractions. We selected 88%, but Tong et al17 chose 91.3%. Our findings
showed that the movements of the subjects in the normal
overall ratio group were significantly remarkable after extraction combinations 1 and 3, suggesting that the toothsize discrepancy might be created by these 2 combinations in some patients with normal overall ratios.
The maxillary and mandibular corrections for the
overall ratios could be used to evaluate a relative toothsize discrepancy. If tooth widths in 1 arch are considered
normal, those in the other arch will be too large or too
small, thus creating reversible, unequal, and opposite discrepancies between the maxillary and mandibular
arches.14 This characteristically antipodal relationship
between maxillary and mandibular corrections was evidenced when we found the movements of subjects in
the small and normal maxillary correction groups corresponded to those in the large and normal mandibular correction groups, respectively, and that most subjects in the
large maxillary correction group and the small mandibular correction group stayed in the same groups after extractions. In this study, the millimetric discrepancy and
the ratio discrepancy suggested that a tooth-size discrepancy might be created by extraction combinations 1 and 3
in some patients with normal maxillary and mandibular
corrections; this was statistically confirmed by the Kruskal-Wallis and Bonferroni tests. The probable reason for
significant differences in the distribution of maxillary
and mandibular corrections between extraction combinations 1 and 3, and 2 and 4, might be that the mesiodistal
width of maxillary second premolars is smaller than that
of maxillary first premolars. A part of our findings about
the changes in the distribution of subjects with millimetric
tooth-size discrepancies agreed with Saatci and Yukay,18
who found that extraction of all first premolars created
more frequent and greater discrepancies than did the other
3 extraction combinations, although they selected subjects not by sex or malocclusion type.
CONCLUSIONS

In formulating a treatment plan involving premolar

extractions, orthodontists should consider that the
overall ratios might decrease, and normal and clinically

American Journal of Orthodontics and Dentofacial Orthopedics

April 2010

significant tooth-size discrepancies could change mutually after extractions.

REFERENCES
1. Bolton WA. Disharmony in tooth size and its relation to the analysis and treatment of malocclusion. Angle Orthod 1958;28:
113-30.
2. Bolton WA. The clinical application of a tooth-size analysis. Am
J Orthod 1962;48:504-29.
3. Lavelle CLB. Maxillary and mandibular tooth size in different racial groups and in different occlusal categories. Am J Orthod
1972;61:29-37.
4. Smith SS, Buschang PH, Watanabe E. Interarch tooth size relationships of 3 populations: does Boltons analysis apply? Am
J Orthod Dentofacial Orthop 2000;117:169-74.
5. Ta TA, Ling JKY, Hagg U. Tooth-size discrepancies among different occlusion groups of southern Chinese children. Am J Orthod
Dentofacial Orthop 2001;120:556-8.
6. Araujo E, Souki M. Bolton anterior tooth size discrepancies
among different malocclusion groups. Angle Orthod 2003;73:
307-13.
7. Crosby DR, Alexander CG. The occurrence of tooth size discrepancies among different malocclusion groups. Am J Orthod Dentofacial Orthop 1989;95:457-61.
8. Uysal T, Sari Z, Bascifftci FA, Memili B. Intermaxillary tooth size
discrepancy and malocclusion: is there a relation? Angle Orthod
2005;75:208-13.
9. Endo T, Abe R, Kuroki H, Oka K, Shimooka S. Tooth size discrepancies among different malocclusions in a Japanese orthodontic
population. Angle Orthod 2008;78:994-9.
10. Freeman JE, Maskeroni AJ, Lorton L. Frequency of Bolton toothsize discrepancies among orthodontic patients. Am J Orthod Dentofacial Orthop 1996;110:24-7.
11. Santoro M, Ayoub ME, Pardi VA, Cangialosi TJ. Mesiodistal
crown dimensions and tooth size discrepancy of the permanent
dentition of Dominican Americans. Angle Orthod 2000;70:
303-7.
12. Endo T, Shundo I, Abe R, Ishida K, Yoshino S, Shimooka S. Applicability of Boltons tooth size ratios to a Japanese orthodontic
population. Odontology 2007;95:57-60.
13. Othman S, Harradine N. Tooth size discrepancies in an orthodontic population. Angle Orthod 2007;77:668-74.
14. Bernabe E, Major PW, Flores-Mir C. Tooth-width ratio discrepancies in a sample of Peruvian adolescents. Am J Orthod Dentofacial Orthop 2004;125:361-5.
15. Proffit WR, Ackerman JL. Contemporary orthodontics. St Louis:
C.V. Mosby; 1986. p. 123-67.
16. Vaden JL, Kiser HE. Straight talk about extraction and nonextraction: a differential diagnostic decision. Am J Orthod Dentofacial
Orthop 1996;109:445-52.
17. Tong H, Chen D, Xu L, Liu P. The effect of premolar extractions
on tooth size discrepancies. Angle Orthod 2004;74:508-11.
18. Saatci P, Yukay F. The effect of premolar extractions on toothsize discrepancy. Am J Orthod Dentofacial Orthop 1997;111:
428-34.
19. Gaidyte A, Baubiniene D. Influence of premolar extractions on
tooth size discrepancy. Part two: analysis of Bolton values. Stomatologija 2006;8:25-9.
20. Japanese Society of Pediatric Dentistry. A study on the cephalometric standards of Japanese children. Jpn J Pediatr Dent 1995;
33:659-96.