Original Article

Lower Second Molar Extraction in Correction of Severe

Skeletal Class III Malocclusion
Jiuxiang Lina; Yan Gub

ABSTRACT
The purpose of this study was to evaluate dentoskeletal and soft-tissue profile changes after ex-
traction of lower second molars and treatment using the Tip-Edge technique in severe Class III
subjects. Thirteen patients with severe skeletal Class III malocclusion (four males, nine females),
diagnosed as requiring orthognathic surgery, but who rejected surgical therapy, were included in
the study. The average age was 13.2 6 0.8 years. Lateral cephalometric films taken at the beginning
and the end of treatment were analyzed using the Pancherz analysis and a traditional cephalometric
analysis. The arithmetic mean and standard deviation were calculated for each variable. Paired t-
test was performed to evaluate significant treatment change. After active treatment, dramatic overjet
change was noted, with an average value of 5.5 mm (P , .001). Inclination of lower incisors was
decreased 12.08 when measured to the mandibular plane (P , .001). Inclination of upper incisors
was increased by 2.18 to the SN plane (P . .05). A negative value of the distance between upper
and lower lip position to Sn-Pg9 at the beginning of treatment changed to a positive value (P ,
.001). The results of this preliminary study suggest that success in the treatment of some severe
Class III deformity in the permanent dentition can be achieved with fixed appliances and extraction
of lower second molars. A remarkable soft-tissue change was noted after the treatment, and con-
cave facial profiles changed to straight profiles. (Angle Orthod 2006;76:217–225.)
KEY WORDS: Skeletal Class III malocclusion; Lower second molars

INTRODUCTION in combination with extractions is considered the only

option for nonsurgical management of skeletal defor-
The decision to treat the severe skeletal Class III
mities in the permanent dentition.
malocclusion by surgical means or nonsurgical ortho-
The MEAW (multiloop edgewise archwire) tech-
dontic approaches still lacks a clear consensus. A fa-
nique is sometimes used for correction of severe Class
cial profile is always one of the main concerns of pa-
III malocclusion.3–5 The extraction index used in the
tients to seek treatment for skeletal Class III deformi-
MEAW technique depends on the overbite depth in-
ties, and orthognathic surgery has been demonstrated
dicator, the anteroposterior dysplasia indicator, es-
to modify the skeletal pattern in addition to producing
thetic line, interincisal angle, and lip position. The low-
dramatic facial profile changes.1,2 However, the major-
er third molars were often extracted with the MEAW
ity of patients in China do not readily accept surgery
technique in Class III subjects.
because of potential surgical complications and seek
Tip-Edge is among the fixed appliances currently
an orthodontic solution. In general, a fixed appliance
used. This appliance characteristically uses a contin-
uous light force of about 50–60 g to achieve tipping
a
Professor, Department of Orthodontics, School of Stoma- movement of teeth and then to upright and move the
tology, Peking University, Bejing, People’s Republic of China.
teeth to an acceptable position.6–13
b
Associate Professor, Department of Orthodontics, School of
Stomatology, Peking University, Bejing, People’s Republic of The purpose of this study is to evaluate dentoskel-
China. etal change and soft-tissue profile change after ex-
Corresponding author: Jiuxiang Lin, BDS, MDS, PhD, De- traction of lower second molars and treatment with
partment of Orthodontics, School of Stomatology, Peking Uni- Tip-Edge in severe Class III subjects.
versity, No. 22 Zhong Guan Cun Southern Street, Beijing
100081, People’s Republic of China (e-mail: jxlin@pku.edu.cn)
MATERIALS AND METHODS
Accepted: April 2005. Submitted: February 2005.
Q 2006 by The EH Angle Education and Research Foundation, Thirteen patients (four male, nine female; mean age
Inc. 13.2 6 0.8 years; range 12.0–17.1 years) with severe

217 Angle Orthodontist, Vol 76, No 2, 2006

218 LIN, GU

skeletal Class III malocclusion in the permanent den-

tition were included in the study. The selection criteria
included (1) full mesial or superior mesial Class III mo-
lar relationship, with maxillary first molar occluding in
the buccal groove of the mandibular second molars;
(2) no mandibular shift; (3) ANB , 21.58; (4) concave
facial profile with high mandibular plane angle from
clinical evaluation; (5) lower third molars present on
panoramics; and (6) originally classified as surgery
cases by other orthodontists.
All cases were treated with Dr Jiuxiang Lin. The Tip-
Edge straight-wire technique was applied in all 13 cas-
es, and all patients were treated with extraction of the
lower second molars. The mean duration of treatment
was 2.6 6 0.6 years.

Cephalometric analysis
Pretreatment and posttreatment cephalograms were
taken with the same cephalostat and traced on an ac-
etate paper. Reference points were marked with a
sharp pencil by one observer, under optimal condi-
tions. The midpoint between the right and left traced
images was used for the bilateral landmarks. Tradi-
tional cephalometric analysis using the Pancherz anal-
ysis with the occlusal plane and occlusal plane per-
pendicular (OLp) as reference grids were performed
(Figure 1).14 The soft-tissue measurements included:
1. UL-SnPg9: The distance of the most convex point
of upper lip to Sn-Pg9 line (line connecting subnose
and soft tissue, Pg);
2. LL-SnPg9: The distance of the most convex point
of lower lip to Sn-Pg9 line; and
3. UL-SnPg9-LL-SnPg9: distance difference of the
most convex points of upper and lower lips to Sn-
Pg9 line.

Statistical analysis
Statistical analysis was performed with SPSS 12.0
for Windows (SPSS Inc, Chicago, IL). The arithmetic
FIGURE 1. (a) Measurements in Pancherz analysis. (b) Reference
mean and standard deviation were calculated for each
lines and landmarks used in traditional cephalometric analysis.
variable. Paired t-test was performed to evaluate treat-
ment effects. The level of significance was P . .05
(NS), *P , .05, **P , .01, and ***P , .001. Molar relationship
Method error The molar relationship was improved by a mean of
Accuracy of linear parameters was 0.2 6 0.2 mm 4.4 mm, which was a significant difference (P , .05;
and angular parameters was 0.18 6 0.38, which is Table 1).
comparable with that used in previous investigations.15
Dental change
RESULTS
The proclination of the upper incisors increased by
Overjet change a mean of 2.18 when measured to the SN plane (P .
Overjet increased dramatically after active treat- .05; Table 2). A mean retroclination of the lower inci-
ment, with the mean value of 5.5 mm (P , .001; Table sors of 12.08 was found when measured to the man-
1). dibular plane (P , .001; Table 2). The mean amount

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CORRECTION OF SKELETAL CLASS III MALOCCLUSION 219

TABLE 1. Results of Cephalometric Analysis

Pretreatment Posttreatment PostTx-PreTx
Mean SD Mean SD Mean SD P Value
Overjet (is/OLp-ii/Olp) 22.4 1.6 3.1 1.3 5.5 1.6 ***
Molar relationship 27.5 5.4 23.1 1.7 4.4 5.0 *
Maxillary base (A/Olp) 74.7 4.9 76.6 6.8 1.9 3.1 *
Mandibular base (Pg/Olp) 92.5 6.5 93.5 8.8 1.0 3.6 NS
Skeletal (A-Pg) 217.8 5.7 216.9 5.5 0.9 2.7 NS
Maxillary incisor (is/Olp) 88.1 6.3 90.7 7.5 2.6 3.5 *
Mandibular incisor (ii/Olp) 90.5 6.5 87.6 8.1 22.8 3.6 *
Maxillary molar (ms/Olp) 56.7 4.2 60.0 6.9 3.1 4.3 *
Mandibular molar (mi/Olp) 65.2 5.4 63.0 7.6 22.2 3.7 NS
Maxillary incisor (is/Olp-A/Olp) 13.3 2.9 14.1 2.2 0.8 2.2 NS
Mandibular incisor (ii/Olp-Pg/Olp) 22.1 4.0 25.9 4.3 23.8 1.5 ***
Maxillary molar (ms/Olp-A/Olp) 218.0 3.0 216.8 3.1 1.2 2.2 NS
Mandibular molar (mi/Olp-Pg/Olp) 226.6 3.8 230.6 5.5 24.0 5.9 *
OL-MnPl 20.5 5.6 23.3 7.2 2.9 3.9 *
PP-MnPl 28.6 6.8 30.0 6.4 1.4 2.9 NS
SN-MnPl 36.0 5.7 37.5 6.5 1.5 4.2 NS
NS indicates not significant (P . .05).
* P , .05.
** P , .01.
*** P , .001.

of lingual movement of the lower incisors was 3.8 mm ginning of treatment changed to a positive value (P ,
when measured from the distance of the tip of the low- .001; Table 2), which indicated a dramatic improve-
er incisors to the occlusal plane perpendicular (P , ment of the concave profile.
.001; Table 1). The amount of labial movement of the
upper incisors was 0.8 mm when measured from the Vertical change
tip of the upper incisor to the occlusal plane perpen-
The mandibular plane remained nearly unchanged
dicular (P . .05; Table 1).
after active treatment, and the palatal plane and oc-
The upper first molar moved to the mesial a mean
clusal plane rotated counterclockwise with a mean val-
of 1.2 mm (P . .05; Table 1). Because of the extrac-
ue of 1.48 (P . .05; Table 1) and 2.98 (P , .05; Table
tion of the lower second molars, the lower first molar
1), respectively.
moved to the distal a mean of 4.0 mm (P , .05; Table
1).
Case report
Skeletal change A 12-year-old girl presented with an anterior cross-
bite and a concave profile (Figures 2 through 7). The
The ANB angle increased a statistically significant
intraoral examination showed a complete Class III mo-
1.38 after treatment (P , .05; Table 2). ‘‘A’’ point
lar relationship on the right side and a super Class III
moved forward at the end of the treatment, with an
molar relationship on the left side. A crossbite of 15 to
increased mean of 1.9 mm (P , .05; Table 1).
25 was noted. A concave facial profile was present, in
An increase in the sagittal position of the mandible
combination with a retrusive maxilla and a protrusive
at point ‘‘Pg’’ to Nasion perpendicular showed a sig-
mandible with no mandibular displacement. Surgical
nificant difference with a mean of 1.0 mm (P . .05;
correction of the skeletal deformity and facial profile
Table 1).
was recommended, but the patient refused the pro-
cedure and insisted on an orthodontic correction.
Soft-tissue change
A Tip-Edge straight-wire appliance was initiated af-
A mean 0.9-mm increase in the distance of the most ter extraction of the lower second molars. After 4
convex point of upper lip to Sn-Pg9 line (P , .05; Table months of Class III elastics, the anterior crossbite was
2) and a 1.8-mm decrease in the distance of the most corrected. Ten months later, a Class I molar relation-
convex point of lower lip to Sn-Pg9 line were noted ship was established. At the end of treatment, the pa-
after treatment (P , .01; Table 2). Furthermore, a neg- tient showed a straight profile, normal overbite, and
ative value of the distance between the most convex overjet. The superimposition of pretreatment and post-
points of upper lip and lower lip to Sn-Pg9 at the be- treatment cephalogram tracings revealed that the ret-

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220 LIN, GU

TABLE 2. Results of Traditional Cephalometric Analysis

Pretreatment Posttreatment PostTx-PreTx
Mean SD Mean SD Mean SD P Value
SNA 81.8 3.4 81.8 2.5 0.0 2.3 NS
SNB 85.5 3.8 84.1 3.2 21.4 2.4 NS
ANB 23.6 2.9 22.3 2.7 1.3 1.9 *
U1-SN 111.8 7.1 113.9 7.4 2.1 7.0 NS
L1-MP 83.8 7.7 71.8 8.0 212.0 7.0 ***
U1-L1 127.2 10.0 134.0 9.5 6.8 10.0 *
UL-SnPg9 5.7 2.1 6.6 2.1 0.9 1.1 *
LL-SnPg9 8.1 2.3 6.3 2.5 21.8 1.9 **
UL-SnPg9/LL-SnPg9 22.4 1.4 0.3 0.8 2.7 1.4 ***
NS indicates not significant (P . .05).
* P , .05.
** P , .01.
*** P , .001.

the anterior crossbite, but it might also be unfavorable

to the correction of molar relationship. Furthermore,
occlusal interlocking of all eight premolars might in-
crease stability after orthodontic therapy, which is cru-
cial to treatment of Class III malocclusion.
Extraction of lower second molars provides more
space needed for the anterior teeth to move backward
to correct anterior crossbites compared with nonex-
traction or lower third molars extraction cases. This is
also essential for the normalization of molar relation-
ship with no need for ‘‘space closure’’ as in premolar
extraction cases. Furthermore, the characteristic of the
Tip-Edge technique is a tipping movement of teeth
with light and continues forces. The initial force of
Class III elastic is relatively light, about 50–60 g. There
is no need to use extraoral forces to strengthen the
anchorage. In this study, anterior crossbites were cor-
rected, and Class I molar and canine relationships
were established in all cases. The lower third molars
FIGURE 2. (a–e) Pretreatment intraoral photographs. erupted in place of the second molars, supporting the
view that the lower third molars make satisfactory re-
placements for second molars.16
roclination of the lower anterior teeth had changed to
a mean of 11.88. A skeletal Class III tendency re-
Consideration when extraction of lower second
mained after the treatment with an ANB of 20.688, but
molars
the facial profile showed a significant improvement. A
follow-up panoramic radiograph showed complete Some clinicians are critical of lower second molar
eruption of the lower third molars. extraction because the third molars do not always
make satisfactory replacements for the lower second
DISCUSSION molars.16 Although overeruption of upper second mo-
lars and mesial eruption of lower third molars occurred
Mechanism of extraction of lower second molars
in several cases in this study, these were corrected
in correction of skeletal Class III malocclusion
with minor adjustment, and a good contact relationship
To correct anterior crossbites and normalize molar was achieved with the lower first molar. Furthermore,
relationship, the upper arch should move forward and numerous clinical evaluation and quantitative studies
the lower arch backward. Therefore, extractions in the have proved that normal-sized lower third molars erupt
upper arch may be undesirable. Extraction of lower in a good position in the majority of cases. Therefore,
teeth mesial to the first molars might aid correction of elimination of complications for surgical removal of im-

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CORRECTION OF SKELETAL CLASS III MALOCCLUSION 221

FIGURE 3. (a–e) Posttreatment intraoral photographs.

pacted third molars is an advantage in favor of lower

second molars extractions.16–19
The indication for extraction of lower second molars
might be (1) severe skeletal Class III malocclusion, (2)
super or full Class III molar relationship, and (3) well-
aligned upper and lower arch or minor crowding in the
lower arch. Extraction of four premolars would not be
suitable for these cases because extraction of upper
premolars could be disadvantageous for the develop-
ment of the maxilla. In addition, extraction of lower pre-
molars might worsen the molar relationship. However,
FIGURE 4. (a–c) Pretreatment facial photographs. extraction of lower third molars might be an alternative

Angle Orthodontist, Vol 76, No 2, 2006

222 LIN, GU

FIGURE 5. (a–c) Posttreatment facial photographs.

therapy in this situation. Obviously, space provided Consideration of third molars

with the extraction of lower third molars is quite limited Extraction of lower second molars provides enough
compared with extraction of lower second molars; this space for distalization of the lower arch and eruption
might be critical in the correction of a Class III molar of lower third molars. In this study, lower third molars
relationship and anterior crossbite. erupted in suitable position in eight cases either during
Extraction of the lower second molars may be a use- the treatment or after a 2-year follow-up. Clinical ex-
ful treatment option in the management of severe perience has demonstrated that the incidence of im-
Class III malocclusion. However, such treatment paction of lower third molars is quite low. In addition,
should be carried out after detailed evaluation of third the third molars might erupt mesially during the treat-
molar position, etc. Although extraction of lower sec- ment or follow-up period, and this might require minor
ond molars provides enough space to move the lower adjustments to achieve a good contact relationship
arch backward compared with the extraction of lower with the lower first molar.
third molars, it has little advantage on relieving crowd- The upper third molars, during their eruption, push
ing in the lower anterior segments. Therefore, to iden- the upper dentition forward, which is favorable in cor-
tify the indication of extraction of lower second molars rection of Class III malocclusion. However, when the
in correction of severe Class III malocclusion is the key lower third molars take the place of lower second mo-
for the success of the treatment. lars, the upper third molars erupt with no opposing
teeth, and overeruption should be considered during
Possible factors contributed to long-term stability the current treatment modality. Indeed, extraction of
of the treatment upper third molars should be carried out when lower
In this study, the eruption of the third molars in prop- third molars have erupted into tight intercuspation with
er position with tight intercuspation with upper second upper second molars.
molars after extraction of lower second molars in eight
cases contributed to the long-term stability of the treat- Influence of extraction of lower second molars on
ment effect. A favorable growth pattern was estab- soft-tissue profile
lished after the active treatment. Although the dental Orthognathic surgery has been demonstrated to
compensatory mechanism in this study needs long- successfully modify the skeletal pattern and bring dra-
term investigation, good periodontal health creates a matic facial profile change. However, the majority of
favorable perioral environment with normalized oral patients with severe Class III in China are unwilling to
muscle activity.20 accept orthognathic surgery.

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CORRECTION OF SKELETAL CLASS III MALOCCLUSION 223

FIGURE 6. (a) Pretreatment panoramic radiograph. (b) Panoramic radiograph of after extraction of lower second molars. (c) Panoramic
radiograph of posttreatment and before eruption of third molars.

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224 LIN, GU

valuable aspects of the study, which makes it accept-

able to treat skeletal Class III cases successfully with
a nonsurgical orthodontic approach. However, the
compensatory mechanism is worthy of further study.

CONCLUSIONS
• Success in treatment of the some severe Class III
deformity in permanent dentition could be achieved
with fixed appliance and extraction of lower second
molars.
• Fixed appliance in combination with extraction of
lower second molars allowed tipping movement of
teeth in a larger range and definite and limited skel-
etal change.
• Remarkable soft-tissue change was noted after ex-
traction of lower second molars, and concave facial
profile changed to straight profile.
• Eruption of lower third molar should be the follow-up
after extraction of lower second molars, and minor
adjustments might be necessary.

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