CLINICIAN'S CORNER

Class II correction: Extraction or

nonextraction?
James L. Vaden,a Richard A. Williams,b and Rebekah L. Goforthc
Cookeville, Tenn, Memphis, Tenn, and Baltimore, Md

The patient with a Class II malocclusion, proclination, or moderate crowding of the mandibular anterior teeth, and
a moderate-to-low mandibular plane angle is a treatment-planning challenge. The records of 3 patients are pre-
sented. For 2 of them, extraction treatment was used to resolve the Class II malocclusion problem. Each of these
patients was treated with the removal of maxillary first premolars and mandibular second premolars. The third
patient was treated with Class II elastics without extractions. The clinician must weigh the pros and cons of
each approach and decide which approach will give the patient the best long-term benefit. (Am J Orthod
Dentofacial Orthop 2018;154:860-76)

T
he patient with a Class II malocclusion and a
moderate-to-low mandibular plane angle and
mandibular incisor crowding or flaring has unique
and, at times, difficult problems that must be resolved.
As with any orthodontic patient, the differential diag-
nosis requires a careful analysis of the face, skeletal
pattern, and dentition so that the treatment plan and
subsequent treatment will yield long-term esthetic and
functional benefits.
The facial esthetics of patients must be a primary
consideration for the clinician. Uprighting of the mandib-
ular incisors can harm the facial balance of many patients
who have a moderate to diminished lower anterior facial
height.1 If this is the case, the mandibular incisors should
be left in their pretreatment positions. Other patients,
however, have a facial pattern that requires at least
some mandibular incisor uprighting to give the face
more balance and harmony. The clinician must discern
the difference and plan accordingly. If patients have
mandibular incisor crowding, these teeth should not be
proclined to eliminate this crowding. A deep curve of
Spee is an additional treatment complexity because
leveling it requires space.2 If the curve of Spee is deep or
there is mandibular incisor crowding, it is not prudent
a
Private practice, Cookeville, Tenn.
b
Department of Orthodontics, University of Tennessee Health Science Center,
Memphis, Tenn.
c
Private practice, Baltimore, Md.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: James L. Vaden, 308 E First St, Cookeville,
TN 38501; e-mail, jlvaden@frontiernet.net.
Submitted, January 2018; revised and accepted, June 2018.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2018.06.010
to flare the mandibular incisors to correct these problems.3
To flare or, conversely, to overly upright the mandibular
incisors can often unfavorably impact the facial profile.
The patient with a moderate-to-low mandibular
plane angle is generally a forward rotator4 who has
diminished dentoalveolar development5 in the maxillary
arch. Barring a surgical approach, the clinician must
move the teeth to the desired position or maintain
them in the pretreatment position.
When the dentition is considered, space-analysis
rules are essentially the same as they are for most ortho-
dontic patients. If the mandibular incisors of a patient
with a Class II malocclusion are in a good position over
basal bone, but moderately crowded or flared, maxillary
first and mandibular second premolar extractions can be
considered if Class II buccal-segment correction is the
goal. This extraction pattern will allow the clinician to
maintain the anteroposterior mandibular incisor posi-
tion, align the crowded mandibular incisors or upright
them if they are proclined, protract the mandibular mo-
lars, and retract flared maxillary incisors. If the mandib-
ular second premolars are extracted, the clinician must
have a command of the mechanics used to upright the
roots of the teeth adjacent to the extraction sites into
the sites. If the uprighting is not done properly, the
extraction spaces will reopen after appliance removal.
The other issue that must be controlled by the clinician
is the amount of mandibular molar protraction vs premolar
and incisor retraction that will occur during mandibular
space closure. If the space is to be closed primarily with
molar protraction, temporary anchorage devices (TADs)
can be used to minimize premolar and incisor retraction.
Another option for malocclusion correction for these
patients is to distalize the entire maxillary arch while

860
Vaden, Williams, and Goforth
holding the mandibular dentition in its pretreatment po-
sition. If this option is selected, it is generally prudent to
carefully analyze the amount of space that is available in
the posterior maxillary dentition area. The maxillary third
molars might need to be extracted to create space for dis-
talization of the remaining maxillary teeth. If this option
is chosen, some sort of TAD augmented anchorage or
skeletal anchorage, either of which will facilitate distal
movement of the maxillary teeth, can be considered.
This type of anchorage will minimize the use of Class II
elastics, which are generally contraindicated due to their
propensity to flare the mandibular incisors.
Another viable option for many Class II patients is to
treat them with removal of the maxillary first premolars
and mandibular third molars—if the mandibular arch has
minimal crowding, if the mandibular incisors have an
acceptable inclination over basal bone, and if the curve
of Spee is not excessive. This treatment plan generally
requires excellent maxillary posterior anchorage because
anchorage loss in the posterior part of the maxillary arch
will limit retraction of the maxillary anterior teeth and
result in some overjet with poor canine coupling at the
end of treatment. Mandibular third molar removal, if
these teeth are half to two thirds developed and imme-
diately distal to the mandibular second molars, creates
space in the posterior part of the mandibular arch so
that the curve of Spee can be leveled by buccal segment
uprighting rather than incisor proclination. To level the
curve of Spee in this manner will require a force system
to the mandibular arch that holds the anterior teeth in
their pretreatment positions.
These treatment plans, as well as a nonextraction
treatment plan, can all be considered to correct a patient
with a moderate-angle Class II malocclusion. The plan
that is chosen must depend on the malocclusion. The
clinician must select a plan that is appropriate.
These clinical case reports will describe the treatment
of 2 patients who were treated with removal of the
maxillary first premolars and mandibular second premo-
lars because this plan can be used to correct many
moderate-to-low angle Class II malocclusions that are
complicated by flared or crowded mandibular incisors
and a deep curve of Spee. The patient with this type of
malocclusion can receive significant facial and dental
benefits if treatment with this extraction pattern is prop-
erly accomplished. The third patient, whose treatment is
described was treated without premolar removal.
PATIENT 1
The pretreatment facial photographs of this 13-year-
old girl (Fig 1) show mandibular lip eversion, convexity
American Journal of Orthodontics and Dentofacial Orthopedics
861
of the facial profile, and mentalis strain. The casts
confirm an Angle Class II malocclusion with a deep over-
bite, a full-step dental Class II relationship, a mild curve
of Spee, and no crowding in the maxillary and mandib-
ular arches. The pretreatment panoramic radiograph
shows a healthy dentition; the pretreatment cephalo-
gram and its tracing confirm a relatively low mandibular
plane angle of 20 , mandibular incisors that are pro-
clined to 105 , and an ANB angle of 7 . The profile
line—a line from chin point tangent to the most promi-
nent lip—is several millimeters in front of the nose. This
profile line to nose relationship is confirmation of the
relative protrusion of the lips (Fig 2). Due to these prob-
lems and the desire to correct the Class II occlusion, the
treatment planning process led to the conclusion that
the maxillary first premolars and mandibular second pre-
molars should be extracted. The extraction of the
mandibular second premolars was done to provide space
to move the mandibular molars forward and upright the
mandibular incisors by a small amount so that lip protru-
sion could be reduced. The maxillary first premolars were
extracted because the maxillary anterior teeth needed to
be intruded and retracted.
A nonextraction option for this patient was requested
by the parent, who agreed with the extraction option af-
ter incisor position, facial profile considerations, and
occlusal correction were explained. Mandibular incisors
must be kept in their pretreatment positions or moder-
ately uprighted if necessary.
The patient was banded and bonded with a standard
edgewise appliance. The maxillary canines were re-
tracted on an 0.018 3 0.025-in archwire with high-
pull J-hook headgear.6 The mandibular arch was leveled
with an 0.018 3 0.025-in edgewise archwire. During
maxillary canine retraction, the mandibular first molars
were protracted with closing loops in the extraction
spaces. Molar protraction was augmented with elasto-
meric chain. These mandibular space closure procedures
were done on a 0.020 3 0.025-in edgewise archwire that
had 6.5-mm closing loops just distal to the first premo-
lars.7 The tie-back that was used to open the closing
loop was bent into the wire just distal to the loop. This
tie-back was then ligated tightly to the first molar to
open the closing loop approximately 1 mm per activa-
tion. This system used all other anterior teeth plus the
premolars as anchorage units and pitted these 8 teeth
against the molars. When this system is used, the clini-
cian must carefully monitor mandibular incisor posi-
tions. Mandibular incisors must be kept in their
pretreatment positions or moderately uprighted if neces-
sary. Their positions must be carefully monitored during
space closure. After the maxillary canines were retracted
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862 Vaden, Williams, and Goforth

Fig 1. Patient 1: pretreatment facial and cast photographs.

and the mandibular molars were protracted, the maxil-
lary anterior teeth were retracted with a
0.020 3 0.025-in maxillary closing loop archwire with
hooks soldered for J-hook headgear attachment so
that the maxillary incisors could be intruded as they
were being retracted. During maxillary anterior tooth
retraction, the mandibular first molars were uprighted
carefully with a 0.019 3 0.025-in archwire with
second-order bends after the mandibular
second molars had been uprighted. Mandibular space
closure was maintained. During the finishing stages of
treatment, maxillary and mandibular 0.020 3 0.025-in
finishing archwires were used. Mild Class II elastics
were worn combined with an anterior vertical elastic
and high-pull J-hook headgear attached to hooks sol-
dered to the maxillary archwire between the maxillary
central and lateral incisors. Treatment time was
22 months. This archwire sequence has been described
in detail because it seemed to work well for a patient
who needed this type of treatment.
The posttreatment facial photographs confirm less
convexity of the facial profile. Lip eversion was elimi-
nated. The posttreatment casts confirm correction of
the Class II dental relationship, opening of the deep
overbite, and leveling of the curve of Spee. Arch form
was maintained (Fig 3). The posttreatment panoramic

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Vaden, Williams, and Goforth
Fig 2. Patient 1: pretreatment panoramic radiograph, cephalogram, and tracing.
radiograph shows significant uprighting of the teeth into
the extraction spaces. The developing third molars will
probably need to be extracted. The posttreatment ceph-
alogram and its tracing confirm maintenance of the
mandibular plane angle, mild uprighting of the mandib-
ular anterior teeth, some retraction of point A, and a
favorable change in the relationship of the profile line
to the lips and the nose (Fig 4).
Superimpositions were done on the cranial base using
the anterior curvature of sella and cranial base structures.
The superimpositions of the maxilla were made by using
the curvature of the palatal plane as well as the key ridge.
Mandibular superimpositions were based on the lingual
curvature of the mandibular symphysis and the inferior
alveolar nerve canal. Pretreatment and posttreatment su-
perimpositions confirm mesial molar movement, mild
mandibular incisor uprighting, and a positive change in
the relationship of the mandible to the maxilla (Fig 5).
The patient was recalled 4 years later. She had not
worn retainers for 2 years. The facial photographs
American Journal of Orthodontics and Dentofacial Orthopedics
863
4 years after treatment (Fig 6) confirm the balance
and harmony of an orthognathic face. The protrusion
has been eliminated. Lip support is good, and there is
no mentalis strain upon closure. The retention casts
show settling of the dentition into an ideal Angle Class
I dental relationship with stability of the arch form,
which was not changed during treatment. It is hoped
that the stability of the dentition will continue
throughout her life. Yes, the teeth will experience
some minor changes, but because she was treated
with maintenance of the arch form and without expan-
sion of the mandibular canines, stability should be
reasonably good.8-10 The recall panoramic radiograph
confirms that the third molars have been removed.
The recall cephalogram and its tracing (Fig 7) confirm
a stable maxillomandibular relationship. The pretreat-
ment, posttreatment, and recall cephalogram superim-
position tracings (Fig 8) illustrate continued favorable
changes in the spacial relationship of the mandible to
the maxilla.
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864 Vaden, Williams, and Goforth

Fig 3. Patient 1: posttreatment facial and cast photographs.

PATIENT 2 malocclusion was not as severe as that of patient num-

The pretreatment facial photographs of this 14-
year-old girl (Fig 9) show mandibular lip protrusion
and mild convexity of the facial profile. The digital
casts confirmed an end-to-end Class II occlusion, a
deep vertical overbite, and 3 mm of mandibular incisor
crowding. The pretreatment panoramic radiograph
confirmed a healthy dentition; the pretreatment ceph-
alogram and its tracing confirmed a relatively low
mandibular plane angle of 20 and an incisor-
mandibular plane angle of 92 . The ANB angle was
only 1 (Fig 10). The patient's cephalometric values
were not as far from normal as those of patient 1.
This patient had no skeletal discrepancy. Because her
ber, she was planned for malocclusion correction
without removal of any permanent teeth.
The patient was banded with a 0.022-in preangu-
lated appliance. Progression of archwires was from
0.016-in nickel-titanium alloy to 0.020-in stainless
steel, to 0.019 3 0.025-in stainless steel. Once all
teeth were aligned, ideal 0.019 3 0.025-in archwires
were inserted. Class II elastics were used to achieve a
Class I dental relationship. Some clinicians would
make records at this juncture in treatment, for this
or similar patients, to ascertain whether extractions
were necessary in order to correct the Class II dental
relationship without further mandibular incisor

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Vaden, Williams, and Goforth 865

Fig 4. Patient 1: posttreatment panoramic radiograph, cephalogram, and tracing.

Fig 5. Patient 1: pretreatment and posttreatment superimpositions.

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866 Vaden, Williams, and Goforth

Fig 6. Patient 1: recall facial and cast photographs.

proclination. This was not done for this patient.
Circumferential elastomeric chain was used to close
all residual spaces (Fig 11). The patient was debanded
after 24 months of treatment. The posttreatment
facial photographs (Fig 12) show a rather procumbent
lower lip and more protrusion of the facial profile
than the patient had at the outset of treatment. The
posttreatment casts confirm a well-interdigitated
Angle Class I occlusion. The posttreatment cephalo-
gram and its tracing (Fig 13) illustrate proclination
of the mandibular incisors from 93 to 104 . The
maxillary incisors were proclined to 120 . The super-
impositions (Fig 14) show protrusion of the mandib-
ular and maxillary incisors along with a more
downward than forward change in the relationship
of the mandible to the maxilla.
The records of this patient, even though she had
only an end-to-end Class II dental relationship, have
been included to illustrate the changes that can occur
if nonextraction Class II correction is accomplished
only with Class II elastics. It can be argued that this pa-
tient could have received a benefit from extraction
treatment. If teeth had been removed at the outset,
the maxillary and mandibular second premolars or
the maxillary first premolars and mandibular second
premolars could have been reasonable choices. For
this patient, space for tooth movement was gained
by proclination of the mandibular teeth. This type of

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Vaden, Williams, and Goforth 867

Fig 7. Patient 1: recall panoramic radiograph, cephalogram, and tracing.

Fig 8. Patient 1: recall superimpositions.

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868 Vaden, Williams, and Goforth

Fig 9. Patient 2: pretreatment facial and digital cast photographs.

treatment can have an impact on the facial profile that
is different from that on the faces of patients who
might be treated with extraction for the correction of
these problems.
PATIENT 3
This patient, a 12-year-old girl, had a marked facial
imbalance, a significant retrognathic profile, and a
deep mentolabial sulcus. The casts show an impinging
overbite and a full-step Class II occlusion. The mandib-
ular incisors were supraerupted. The occlusal views of
the casts show mild maxillary anterior crowding and
no mandibular crowding (Fig 15). The pretreatment
cephalogram and its tracing (Fig 16) confirm protrusion
of the teeth that impacted the lower third of the face.
The incisor-mandibular plane angle was 110 . The
ANB angle was 9 .
For this patient, the mandibular incisors needed up-
righting, the maxillary incisors needed retraction with
proper third-order maintenance, and the posterior teeth
needed to be moved to a Class I occlusal relationship.
One way to accomplish these goals is to obtain space
for tooth movement. The maxillary first premolars and
the mandibular second premolars were removed. One
could consider extraction of only the maxillary first pre-
molars, but this option would have left the mandibular

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Vaden, Williams, and Goforth
Fig 10. Patient 2: pretreatment panoramic radiograph, cephalogram, and tracing.
incisors flared. The flared mandibular incisors would
have a negative impact on maxillary anterior retraction.
Some clinicians might consider TADs and attempt to dis-
talize the entire maxillary dentition. This approach
would be limited by the mandibular incisor proclination.
These 2 possibilities were considered but eliminated.
The patient was treated using the protocol described for
patient 1. The initial archwires were 0.016 3 0.022-in
maxillary and 0.017 3 0.022-in mandibular. Archwire
dimensions were increased after 3 months to
0.019 3 0.025-in maxillary and 0.020 3 0.025-in
mandibular. Maxillary canine retraction was overcom-
pleted on the 0.019 3 0.025-in archwire. A maxillary
closing loop archwire of 0.020 3 0.025 in was inserted.
Mandibular spaces were closed on a 0.020 3 0.025-in
archwire as were the maxillary spaces. Finishing arch-
wires were 0.020 3 0.025-in maxillary and
0.0215 3 0.0275-in mandibular because Class II elastics
were used during finishing. Mandibular incisor position
was controlled during treatment. The mandibular molars
were protracted, and the maxillary anterior teeth were
intruded as well as retracted. Proper third-order root po-
sition was maintained.
American Journal of Orthodontics and Dentofacial Orthopedics
869
The posttreatment facial photographs (Fig 17) show
an acceptable curve of the upper lip and an improved
facial profile. The frontal view of the face exhibits less
eversion of the lower lip. The posttreatment casts show
correction of the deep vertical overbite, correction of
the Class II dental relationship, leveling of the curve of
Spee, and maintenance of the arch form. All extraction
spaces have been closed. The posttreatment panoramic
x-ray (Fig 18) shows uprighting of the mandibular first
molars into the second premolar extraction sites and
acceptable root paralleling of the teeth. The posttreat-
ment cephalogram and its tracing confirm maintenance
of the mandibular plane angle, uprighting of the
mandibular incisors from 110 to 92 , and a decrease
in the ANB angle from 9 to 5 . The pretreatment and
posttreatment superimpositions (Fig 19) confirm mesial
mandibular molar movement, uprighting of the mandib-
ular anterior teeth, and intrusion and retraction of the
maxillary anterior teeth. The superimpositions illustrate
a downward and forward change of the mandible in
relation to the maxilla.
A nonextraction treatment plan for this patient
would have been a significant challenge. The
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870 Vaden, Williams, and Goforth

Fig 11. Patient 2: interim photographs.

mandibular incisors were too proclined to leave them
that way. To attempt to treat her without premolar ex-
tractions would probably have compromised facial es-
thetics and the ability of the mandible to come
downward and forward with growth due to incisor pro-
clination. For these reasons, she was treated with maxil-
lary first premolar and mandibular second premolar
extractions.
Retention
The 2 extraction patients whose records were pre-
sented here were retained with maxillary and mandib-
ular Hawley retainers. Their retention protocol was
initiated in the following manner: (1) all appliances
were removed, and impressions were made; (2)
maxillary and mandibular Hawley retainers were deliv-
ered a week after appliance removal; (3) retainers were
adjusted at 1 month and subsequently at 6-month in-
tervals; and (4) Hawley retainers were or will be worn
for 18 months.
The nonextraction patient was retained with a
maxillary Hawley retainer and a mandibular fixed
canine-to-canine retainer with an Essix overlay. The
Hawley will be adjusted at 6-month intervals. The
fixed mandibular retainer will be monitored indefi-
nitely.
DISCUSSION
Class II correction treatment protocols continue to be
a controversial subject in orthodontics. Attempts to

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Vaden, Williams, and Goforth 871

Fig 12. Patient 2: posttreatment facial and cast photographs.

Fig 13. Patient 2: posttreatment cephalogram and tracing.

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872 Vaden, Williams, and Goforth

Fig 14. Patient 2: pretreatment and posttreatment superimpositions.

Fig 15. Patient 3: pretreatment facial and cast photographs.

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Vaden, Williams, and Goforth
Fig 16. Patient 3: pretreatment panoramic radiograph, cephalogram, and tracing.
grow a mandible have proven to be unsuccessful.11-13
Expansion, particularly of the mandibular dentition, is
notoriously unstable.14,15 For the 2 Class II extraction
patients whose treatments have been described, the
maxillary anterior teeth were retracted while the
mandibular first molars were mesialized. Mandibular
anterior tooth positions were adjusted during the
patient's normal growth. The patient treated without
extractions did not have the benefit of these tooth
movements.
Bjork and Skieller16 have proven with implant
studies that the maxillomandibular relationship stays
the same unless changed by orthodontic treatment.
Successful Class II correction depends on tooth move-
ment as well as a favorable response of the mandible to
an orthodontic force system. If a Class II malocclusion
correction is accomplished by moving all mandibular
teeth forward, there are facial and stability conse-
quences.17-19 If molars are extruded during Class II
treatment, and if mandibular anterior teeth are
American Journal of Orthodontics and Dentofacial Orthopedics
873
flared, the mandible must rotate down and back as it
grows.20,21
Space to correct a Class II dental relationship
should be available or made available. All orthodon-
tists agree that the stability of the Class II dental
correction must be excellent and that the facial profile
of the Class II patient needs balance and harmony.
Facial esthetics should be improved or maintained,
not harmed. When it boils down to 2 goals, improve
or maintain the face and correct the occlusion, the
clinician must make the decision that is most appro-
priate for each patient. The maxillary first premolar
and mandibular second premolar extraction protocol
is an acceptable method of gaining the required space
for patients who will benefit from it. The ultimate de-
cision of whether to extract or to treat without extrac-
tions, however, must be made by the clinician. Other
options for Class II malocclusion corrections are non-
extraction with distalization of the maxillary dentition
with TADs or some sort of rigid bone-supported
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874 Vaden, Williams, and Goforth

Fig 17. Patient 3: posttreatment facial and cast photographs.

anchorage,22-24 and maxillary first premolar
extractions that result in a Class I canine and Class
II molar occlusion. This option requires an excellent
pretreatment mandibular arch and good maxillary
posterior anchorage. Both treatment options are
excellent if the patient's problem is conducive to
their use. The purpose of this clinical article was to
illustrate the first premolar and mandibular second
premolar extraction option. The downside to this
extraction pattern is obviously overretraction of the
mandibular and maxillary incisors. To place these
teeth into their proper axial and anteroposterior
positions requires a command of whatever force
system is used. The system used with our 2
extraction patients is not the only system that will
work. Many approaches will work—and work well.
The overriding issue that any system must address is
management of the extraction space.
CONCLUSIONS
We have described the correction of 3 routine Class II
malocclusions. One was treated without extraction; 2
were treated with extraction. The clinician must decide
what approach is in the best interest of each patient.
The critical issue is space: where will it be obtained so
that the teeth can be put into the desired position?
This decision must be made by the clinician after he or
she considers the face, skeletal pattern, and dentition.

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Fig 18. Patient 3: posttreatment panoramic radiograph, cephalogram, and tracing.

Fig 19. Patient 3: Pretreatment and posttreatment superimpositions.

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876
ACKNOWLEDGMENTS
We thank John Grubb of Escondido, Calif, for his help
with the figures and Patricia Page of Cordova, Tenn, for
her help with the figures and technical aspects of this
article.
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