Odontology (2009) 97:4350 DOI 10.

1007/s10266-008-0093-0

The Society of The Nippon Dental University 2009

ORIGINAL ARTICLE

Koji Kojima Toshiya Endo Shohachi Shimooka

Effects of maxillary second molar extraction on dentofacial morphology before and after anterior open-bite treatment: a cephalometric study

Received: July 11, 2008 / Accepted: August 25, 2008

Abstract The purpose of the present study was to probe into the effects of maxillary second molar extraction on dentofacial morphology by the use of cephalometric radiographs taken before and after anterior open-bite treatment. The subjects were 30 Japanese patients who had received multiloop edgewise archwire therapy without premolar extraction. They were divided into two groups. Group 1 consisted of 15 patients who had their maxillary second molars removed. Group 2 comprised 15 patients who had been treated without extraction of maxillary second molars. Lateral cephalograms were taken before and after treatment. Seventeen angular and 31 linear measurements were obtained from the lateral cephalograms. Paired and unpaired t tests were used to determine the signicance of differences in measurements. The retrusion and extrusion of the maxillary incisors, the distal movement of the maxillary rst molars, and the uprighting of the maxillary rst premolars and the mandibular rst molars were greater in group 1 than in group 2. Moreover, the maxillary rst molars intruded signicantly in group 1 but extruded insignicantly in group 2. Extraction of maxillary second molars, as well as nonextraction, can be an effective operating procedure for open-bite correction of the permanent dentition. Key words Open bite Maxillary second molar extraction Nonextraction Multiloop edgewise archwire therapy Lateral cephalogram

Introduction
Anterior open-bite is a very common anomaly, yet its treatment is most difcult because relapse occurs easily.1,2 Highpull headgears,2,3 high-pull chin caps,3,4 tongue cribs,3,4 molar bite blocks,5 functional orthodontic appliances,6 edgewise appliances,13 and vertical elastics13 are used in the treatment of growing young patients, and edgewise appliances are almost exclusively employed for adult patients. Edgewise appliances have been also used in surgical orthodontic treatment for severe skeletal open-bite cases.7 Recently, zygomatic implants8 or microscrew implants9 have come to be used as anchorage units together with edgewise appliances. Open-bite treatment modalities using edgewise appliances include premolar extraction2,10,11 or nonextraction treatment1,1214 in addition to molar extraction treatment.10,11,1416 Changes in dentofacial morphology commonly seen in these types of open-bite treatment are reported to be retroclination, retrusion, and extrusion of maxillary as well as mandibular incisors, and increased facial height due to extrusion of molars.1,1214 Some investigators have demonstrated the mesial movement of molars and a marked retroclination of anterior teeth in premolar extraction treatment,3 while others have reported the distal movement of premolars and rst molars in second molar extraction treatment.15 Among the factors contributing to the incidence of open bite, molar crowding15 and posterior discrepancies16 have been suggested. Kim and colleagues3,10 eliminated posterior discrepancies by extracting the third or second molar and succeeded in treating open-bite cases using a multiloop edgewise wire (MEAW) therapy. As long as X-rays show nothing wrong with coronal morphology or the direction of tooth eruption, extraction of maxillary and mandibular second molars is performed in the treatment of various forms of malocclusion to eliminate posterior discrepancies.1519 Moft18 and Basdra et al.19 found that maxillary third molars replaced second molars quite successfully. Chipman20 stated that there are concerns about the prognosis of replacement of mandibular second

K. Kojima (*) T. Endo Orthodontic Dentistry, The Nippon Dental University Niigata Hospital, 1-8 Hamaura-cho, Chuoh-ku, Niigata 951-8580, Japan Tel. +81-25-267-1500; Fax +81-25-265-5819 e-mail: koji-kou@ngt.ndu.ac.jp S. Shimooka Department of Pediatric Dentistry, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan

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molars by third molars, and for that reason maxillary second molars are extracted more frequently than their mandibular counterparts. In our previous study, we cephalometrically examined changes in dentofacial morphology of patients with anterior open-bite malocclusion who had undergone MEAW therapy without extraction of premolars, and considered that maxillary second molar extraction would contribute effectually to open-bite correction because maxillary canines and premolars were uprighted marvelously compared with those in the nonextraction group.14 The purpose of the present study was to probe into the effects of maxillary second molar extraction on dentofacial morphology by the use of cephalometric radiographs taken before and after anterior open-bite treatment.

sides were observed, and in the remaining subject, a mandibular right third molar was observed. All of the mandibular third molars were extracted before or during the active treatment. Group 2 comprised 15 female subjects who had been treated without extraction of maxillary second molars. In eight of the 15 subjects, there were no maxillary or mandibular third molars on either side. In three others, four third molars were observed in the maxillary or mandibular arch; in an additional two subjects, mandibular third molars; in another, a maxillary right third molar; and in the one remaining subject, a mandibular left third molar. All of these third molars were removed before or during the active treatment.

Treatment methods

Materials and methods

The subjects selected for this study consisted of 30 consecutive Japanese patients with anterior open-bite malocclusion who had received successful orthodontic treatment without premolar extraction at the orthodontics clinic of the Nippon Dental University Niigata Hospital (Niigata, Japan). They were selected according to the following criteria: mandibular central incisor edges positioned beneath the maxillary occlusal plane on the lateral cephalometric radiographs; full eruption of all the maxillary and mandibular teeth up to the second molars; Angle class I malocclusion; no craniofacial anomalies; no prior orthodontic or prosthetic treatment; and willingness to participate in our study. The subjects were divided into two groups. The mean ages of the two groups at pretreatment (T1) and posttreatment (T2) and the mean length of time required for treatment (T2 T1) are shown in Table 1. Group 1 consisted of 15 individuals (three male and 15 female patients) who had their maxillary left and right second molars removed. Since pretreatment lateral cephalometric radiographs did not reveal any sex difference in craniofacial morphology, data for male and female patients were combined. They all had maxillary third molars on both sides. There was nothing anomalous about the coronal morphology or eruption direction of the third molars. After active treatment, all of the maxillary third molars erupted in the very place that the second molars should have occupied, and came into contact with the distal proximal surface of the maxillary rst molars. In 14 of the 15 subjects, mandibular third molars on both Standard edgewise appliances (0.018 0.025 inches; 0.4572 0.635 mm) were used in the treatment with MEAW therapy. For leveling and alignment, 0.016-inch (0.4064 mm) nickel-titanium wires were used rst, and then 0.016 0.016 inch nickel-titanium wires. To close the open bite and achieve a correct occlusion, maxillary and mandibular multiloop stainless steel archwires (0.016 0.022 inches; 0.4064 0.5588 mm) with anterior vertical elastics were used. After active orthodontic treatment, Hawley retainers were used in the maxillary and mandibular arches.

Cephalometric analysis Lateral cephalometric radiographs of each subject were taken at the T1 and T2 stages using the same cephalostat at a standard setting. Cephalometric tracings were drawn on matte acetate paper, and linear and angular measurements were made by one researcher (K.K.). The measurements were recorded to the nearest 0.1 mm and 0.5. For each tracing, 20 reference points were marked, and 17 angular and 31 linear measurements were made with a protractor and a vernier micrometer (Fig. 1, Table 2). Seventeen linear measurements (for example, U1e-x and U1e-y for distances from the maxillary incisor edge to the x-axis and the y-axis, respectively) were made using a coordinate system with the x-axis parallel to the Frankfort horizontal plane and the y-axis perpendicular to the Frankfort horizontal plane through the sella turcica (Fig. 1, Table 2).

Table 1. Mean ages of the two groups at pretreatment and posttreatment and the mean duration of treatment Age (years) Pretreatment (T1) Mean Group 1 Group 2 15.3 20.4 SD 2.8 6.5 Posttreatment (T2) Mean 17.3 22.0 SD 2.4 6.5 Treatment time Mean 2.0 1.7 SD 0.8 1.0

45

N S

Results
SN x-axis

Po Ar Ptm PNS U6 U4 U6

Or

FH

U4 U1

ANS A

PP

L6 Go

L4

U1e L1e

OP

B L6 L4 Me L1 Pog Gn Y-axis MP

RP y-axis

Unpaired t tests showed that the mean pretreatment age differed signicantly between groups 1 and 2 (P < 0.01), but no signicant differences in the mean length of time required for treatment were noted between two groups. The measurements from lateral cephalometric radiographs and the results of statistical analyses are shown in Tables 3 and 4. Between groups 1 and 2, signicant differences were noted only in prognathism of the maxillary alveolar bone (SNA), ramus height (Go-Ar), maxillary molar inclination (U6PP), and lower posterior facial height (Ar-Go) at the pretreatment stage (Table 3: S1). Since signicant differences were noted in no more than four items out of a total of 48 measurement items, we thought it worthwhile compare the two groups (Table 3: S1).

Fig. 1. Reference points and lines used for lateral cephalometric analysis. N, nasion; S, sella turcia; Or, orbitale; Po, porion; Ar, articulare; ANS, anterior nasal spine; PNS, posterior nasal spine; Ptm, pterygomaxillary ssure; A, point A; U1e, maxillary incisor edge; L1e, mandibular incisor edge; B, point B; Pog, pogonion; Gn, gnathion; Me, menton; Go, gonion; U4, the tips of the maxillary rst premolar buccal cusp; L4, the tip of the maxillary rst premolar buccal cusp; U6, the most superior point on the maxillary rst molar buccal groove; L6, the most superior point on the mandibular rst molar buccal groove; SN, sella turcica-nasion plane; FH, Frankfort plane; PP, palatal plane; OP, occlusal plane; MP, mandibular plane; RP, ramus plane; Y-axis, sella turcica-gnathion line; U1, long axis of maxillary central incisor; L1, long axis of mandibular central incisor; U4, long axis of maxillary rst premolar; L4, long axis of mandibular rst premolar; U6, long axis of maxillary rst molar; L6, long axis of mandibular rst molar; x-axis, a line parallel to the Frankfort horizontal plane through the sella turcica; y-axis, a line perpendicular to the Frankfort horizontal plane through the sella turcica

Cranial base measurements None of the cranial base measurements showed any signicant changes in either group 1 or group 2 (Tables 3 and 4: S2) or between the two groups (Table 3: S3) from T1 to T2.

Maxillary and mandibular measurements No signicant changes in measurements from T1 to T2 were observed in group 1 (Table 3: S2). In contrast, a signicant increase in measurements for facial convexity (ANB) was noted in group 2 (Table 4; S2). None of the measurement items showed any signicant difference in values from T1 to T2 in either group 1 or group 2 (Table 3: S3).

Statistical analysis Dentoalveolar measurements Analyses were carried out with the StatMate III statistical program (ATMS, Tokyo, Japan). Paired t tests were used to determine the signicance of differences in measurements in each group made from T1 and T2 cephalometric radiographs. Unpaired t tests were used to test the signicance of differences in measurements between groups 1 and 2 before treatment and the signicance of differences in changes in measurements from T1 to T2 between the two groups. In groups 1 and 2, the posttreatment measurements revealed that the distance from the maxillary incisor edge to the x-axis (U1e-x), from U4 to the palatal plane (U4-PP), from the mandibular incisor edge to the mandibular plane (L1eMP), from L4 to the mandibular plane (L4-MP), and from L6 to the mandibular plane (L6-MP) and overbite and the interincisal angle (U1-L1) increased signicantly, while the maxillary incisor inclination (U1-SN), maxillary rst premolar inclination (U4-PP), mandibular incisor inclination (L1-MP), mandibular rst premolar inclination (L4-MP), maxillary molar inclination (U6-PP) ,and mandibular molar inclination (L6-MP) decreased signicantly (Tables 3 and 4: S2). These results indicate the occurrence of extrusion and retroclination of maxillary and mandibular central incisors, extrusion and uprighting of maxillary and mandibular rst premolars and rst molars, and uprighting of maxillary rst molars. In group 1, moreover, the distance from the maxillary incisor edge to the y-axis (U1e-y), the distance from U6 to the y-axis (U6-y), and the distance from U6 to the palatal plane (U6-PP) decreased signicantly, indicating

Method error For evaluation of errors in tracing, landmark identication, and measurements, 20 randomly selected cephalometric radiographs were retraced and measured again by the same researcher 1 month later. Students t test with a 95% condence interval did not nd any systematic errors. Method errors, calculated according to Dahlbergs formula,21 did not exceed 0.4 or 0.3 mm, which were acceptable in this study.1,2,12,14

46 Table 2. Denitions of reference points and lines Measurement Cranial base measurements S-N (mm) S-Ar (mm) N-Ar (mm) N-S-Ar () Denition Anterior cranial base length Overall cranial base length Posterior cranial base length Cranial base angle

Maxillary and mandibular measurements ANS-PNS (mm) Maxillary length A-y (mm) Distance from point A to the y-axis Ptm-y (mm) Distance from pterygomaxillary ssure to the y-axis S-N-A () Prognathism of maxillary alveolar bone PP-SN () S-N to palatal plane angle Me-Go (mm) Mandibular body length Go-Ar (mm) Ramus height Ar-Me (mm) Maximum mandibular length B-y (mm) Distance from point B to the y-axis S-N-B () Prognathism of mandibular alveolar bone MP-SN () Mandibular plane angle Y axis-SN () Y-axis inclination relative to S-N plane RP-SN () Ramus inclination MP-RP () Gonial angle A-N-B () Facial convexity Dentoalveolar measurements U1e-x (mm) U1e-y (mm) U1-SN () L1e-x (mm) L1e-y (mm) L1-MP () L1e-MP (mm) Overjet (mm) Overbite (mm) U4-PP (mm) U4-PP () L4-MP (mm) L4-MP () U6-x (mm) U6-y (mm) U6-PP () U6-PP (mm) L6-x (mm) L6-y (mm) L6-MP () L6-MP (mm) U1-L1 () OP-SN () Vertical measurements N-Me (mm) ANS-N (mm) ANS-Me (mm) S-Go (mm) S-Ar (mm) Ar-Go (mm) Distance from maxillary incisor edge to the x-axis Distance from maxillary incisor edge to the y-axis Maxillary incisor inclination Distance from mandibular incisor edge to the x-axis Distance from mandibular incisor edge to the y-axis Mandibular incisor inclination Distance from mandibular incisor edge to mandibular plane Overjet Overbite Distance from U4 to palatal plane Maxillary rst premolar inclination Distance from L4 to mandibular plane Mandibular rst premolar inclination Distance from U6 to the x-axis Distance from U6 to the y-axis Maxillary rst molar inclination Distance from U6 to palatal plane Distance from L6 to the x-axis Distance from L6 to the y-axis Mandibular molar inclination Distance from L6 to mandibular plane Interincisal angle Occlusal plane inclination Total anterior facial height Upper anterior facial height Lower anterior facial height Total posterior facial height Upper posterior facial height Lower posterior facial height

that in group 1 retrusion of the maxillary central incisors and intrusion and distal movement of the maxillary rst molars were evident. In both groups, as a result of the extrusion of the maxillary and mandibular rst premolars, the occlusal vertical dimension in the rst premolar regions increased. In group 1, the extrusion of the mandibular rst molars exceeded the intrusion of the maxillary rst molars with the result that the occlusal vertical dimension in the rst molar regions increased. In group 2, the extrusion of the maxillary and mandibular rst molars increased the vertical dimension of occlusion in the rst molar regions.

The U1e-x, U6-y, and U6-PP distances, and the U4-PP and L6-MP angles, showed signicant differences in the amount of change from T1 to T2 between the two groups (Table 3: S3).

Vertical measurements Signicant increases were noted in total anterior facial height (N-Me) and lower anterior facial height (ANS-Me) from T1 to T2 in both groups (Tables 3 and 4: S2). In terms

47 Table 3. Lateral cephalometric analysis in group 1 Pretreatment (T1) Mean Cranial base measurements S-N (mm) 68.3 S-Ar (mm) 36.2 N-Ar (mm) 93.9 N-S-Ar () 125.2 Maxillary and mandibular measurements ANS-PNS (mm) 48.8 A-y (mm) 64.2 Ptm-y (mm) 17.8 S-N-A () 78.6 PP-SN () 8.7 Me-Go (mm) 71.5 Go-Ar (mm) 45.3 Ar-Me (mm) 107.5 B-y (mm) 58.2 S-N-B () 76.7 MP-SN () 41.0 Y axis-SN () 73.7 RP-SN () 91.8 MP-RP () 129.0 A-N-B () 1.9 Dentoalveolar measurements U1e-x (mm) 76.4 U1e-y (mm) 72.0 U1-SN () 111.1 L1e-x (mm) 77.3 L1e-y (mm) 68.5 L1-MP () 94.6 L1e-MP (mm) 44.5 overjet (mm) 3.5 overbite (mm) 0.9 U4-PP (mm) 26.2 U4-PP () 98.6 39.2 L4-MP (mm) L4-MP () 84.0 68.3 U6-x (mm) U6-y (mm) 36.4 U6-PP () 77.5 U6-PP (mm) 21.6 71.9 L6-x (mm) 39.1 L6-y (mm) L6-MP () 86.4 L6-MP (mm) 33.1 U1-L1 () 113.4 OP-SN () 20.0 Vertical measurements N-Me (mm) ANS-N (mm) ANS-Me (mm) S-Go (mm) S-Ar (mm) Ar-Go (mm) 126.6 56.4 70.3 77.8 32.9 44.9 SD 2.5 2.1 2.8 4.0 3.5 3.1 2.8 2.8 4.0 4.6 4.0 4.8 5.6 2.8 4.2 3.0 4.9 6.0 3.5 3.3 4.5 6.6 3.3 4.7 8.3 2.4 3.2 1.6 1.4 8.5 2.0 7.5 2.8 4.5 5.3 1.3 3.2 4.6 5.1 2.9 9.4 4.2 4.6 2.7 2.8 4.0 4.1 4.4 NS NS NS NS NS NS NS * NS NS * NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS ** NS NS NS NS NS NS NS NS NS NS NS NS * S1 Posttreatment (T2) Mean 68.4 36.6 94.2 124.0 48.8 64.3 17.3 79.0 8.4 72.4 46.5 108.7 57.2 76.7 41.4 72.1 92.8 128.2 2.3 79.4 70.0 102.7 78.1 67.7 90.7 46.7 2.3 1.3 27.8 83.2 41.7 76.4 69.4 34.3 73.6 21.1 73.1 37.7 79.0 34.2 124.1 20.3 129.3 57.2 72.0 78.5 32.5 46.0 SD 2.5 2.5 4.0 4.6 3.4 3.8 2.9 2.7 3.8 4.1 3.9 6.1 6.2 3.5 4.4 8.9 7.0 5.4 3.7 2.9 4.3 9.5 2.9 4.2 8.2 3.2 0.5 0.9 1.8 6.3 2.7 5.5 3.0 3.9 5.2 1.4 4.3 4.0 6.5 3.0 6.9 5.0 6.2 3.3 4.3 5.1 2.3 4.4 NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS *** * ** NS NS * *** NS *** ** *** ** ** NS ** * * NS NS *** ** *** NS * NS * NS NS NS S2 Treatment change Mean 0.1 0.4 0.3 1.2 0.0 0.1 0.5 0.3 0.3 0.8 1.2 1.2 1.0 0.1 0.4 1.6 1.0 0.8 0.4 3.0 1.9 8.5 0.8 0.8 3.9 2.3 1.1 2.2 1.6 13.4 2.5 6.6 1.1 2.1 3.9 0.5 1.3 1.4 7.4 1.2 10.7 0.4 2.7 0.9 1.7 0.8 0.4 1.2 SD 1.0 1.7 2.3 3.1 1.0 1.6 1.3 1.3 2.1 1.5 3.4 3.3 2.6 1.3 2.6 8.5 5.3 2.3 1.3 2.0 2.8 9.3 2.8 2.1 5.8 1.7 3.0 1.5 1.6 7.6 2.4 7.1 2.3 2.3 5.2 0.9 2.7 2.8 6.2 1.1 8.0 4.1 4.0 1.6 2.8 4.4 3.5 4.5 NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS * NS NS NS NS NS NS NS NS NS * NS NS NS * NS ** NS NS * NS NS NS NS NS NS NS NS NS S3

***P < 0.001; **P < 0.01; *P < 0.05; NS not signicant S1, statistical comparison between groups 1 and 2 at T1; S2, statistical comparison between T1 and T2; S3, statistical comparison of treatment changes between groups 1 and 2

48 Table 4. Lateral cephalometric analysis in group 2 Pretreatment (T1) Mean Cranial base measurements S-N (mm) S-Ar (mm) N-Ar (mm) N-S-Ar () 67.9 36.4 93.7 125.4 SD 3.4 3.4 5.0 3.8 3.2 4.4 2.3 3.4 2.4 5.2 5.3 7.0 8.3 4.0 5.0 4.7 7.5 7.2 3.2 5.6 5.8 9.1 6.3 6.8 7.7 3.4 3.2 1.7 2.1 5.5 3.4 6.9 4.8 6.0 4.4 2.2 5.0 6.1 5.4 4.1 10.0 3.7 6.9 2.0 6.0 6.7 3.6 5.2 Posttreatment (T2) Mean 68.2 36.0 93.6 125.2 52.0 66.9 18.1 81.9 10.2 73.5 49.8 111.0 58.9 77.9 39.0 73.1 94.4 123.9 4.0 80.3 72.2 100.9 79.4 69.7 92.4 46.1 2.5 0.9 28.1 87.2 41.7 77.8 71.2 36.6 80.7 23.4 73.7 39.8 81.0 35.0 126.0 20.9 129.7 57.8 71.9 81.4 32.1 49.4 SD 3.5 3.0 4.9 4.0 2.6 4.6 2.2 3.3 3.1 5.3 4.9 7.0 7.9 3.8 5.5 4.3 6.3 8.3 2.8 6.3 5.2 8.0 6.6 5.0 9.1 3.6 0.8 0.9 2.0 5.3 2.8 6.4 5.5 5.3 4.7 2.3 5.3 5.5 6.5 4.3 8.9 5.1 7.6 2.1 6.9 6.4 2.8 5.1 NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS ** * NS ** NS NS ** *** NS ** ** *** ** *** NS NS * NS NS NS * * *** NS * NS * NS NS NS S2 Treatment change Mean 0.3 0.4 0.0 0.2 1.1 1.0 0.0 0.2 0.2 0.3 0.7 0.4 0.5 0.7 0.8 0.2 0.8 1.4 0.9 1.2 1.6 7.5 0.5 0.3 3.7 1.4 1.2 1.7 1.0 6.8 1.7 5.3 0.7 0.3 2.0 0.6 0.1 0.2 3.0 0.7 10.9 0.6 1.4 0.3 1.1 0.6 0.3 0.3 SD 0.6 1.0 1.4 2.3 2.3 2.3 0.7 1.9 1.9 2.5 2.0 2.0 3.7 1.5 3.1 2.2 3.8 3.0 1.0 2.2 3.4 7.3 2.8 3.6 4.0 1.0 3.2 1.8 1.0 5.6 1.7 4.7 2.0 2.5 3.3 1.1 1.8 2.9 4.8 1.3 7.3 4.6 1.9 0.9 1.9 2.5 1.6 2.8

Maxillary and mandibular measurements ANS-PNS (mm) 51.0 A-y (mm) 65.9 Ptm-y (mm) 18.2 S-N-A () 81.7 PP-SN () 10.5 Me-Go (mm) 73.2 Go-Ar (mm) 49.0 Ar-Me (mm) 110.6 B-y (mm) 59.4 S-N-B () 78.6 MP-SN () 38.2 Y axis-SN () 73.0 RP-SN () 93.6 MP-RP () 125.3 A-N-B () 3.1 Dentoalveolar measurements U1e-x (mm) 79.1 U1e-y (mm) 73.7 U1-SN () 108.4 L1e-x (mm) 79.9 L1e-y (mm) 70.1 L1-MP () 96.1 L1e-MP (mm) 44.6 overjet (mm) 3.7 overbite (mm) 0.8 U4-PP (mm) 27.1 U4-PP () 95.1 40.1 L4-MP (mm) L4-MP () 83.9 70.4 U6-x (mm) U6-y (mm) 36.9 U6-PP () 82.8 U6-PP (mm) 22.8 L6-x (mm) 73.6 40.1 L6-y (mm) L6-MP () 84.1 L6-MP (mm) 34.3 U1-L1 () 115.1 OP-SN () 20.3 Vertical measurements N-Me (mm) ANS-N (mm) ANS-Me (mm) S-Go (mm) S-Ar (mm) Ar-Go (mm) 128.3 57.5 70.8 80.8 31.7 49.1

***P < 0.001; **P < 0.01; *P < 0.05; NS not signicant S2, statistical comparison between T1 and T2

49

of the amount of change, none of the measurement items showed signicant differences between the two groups (Table 3: S3).

Discussion
The results of our study did not show any signicant change in cranial base measurements or maxillary and mandibular measurements during active orthodontic treatment in either group, except for the ANB angle in group 2. These ndings are in agreement with those of studies on anterior open-bite treatment in the permanent dentition.1,2,10,12,14 Our ndings also indicated that facial growth and development had been almost completed in all subjects, which led us to believe that the difference in the mean age between the two groups at T1 had not affected the treatment outcome despite the fact that the mean age difference was statistically signicant. In group 2, the ANB angle increased signicantly. Conceivably, this might have resulted from downward rotation of the mandible due to the statistically signicant extrusion of the maxillary and mandibular rst premolars and the mandibular rst molars and the extrusion of the maxillary rst molars, since facial growth had ceased. This conjecture is based on the observations made by Isaacson et al.22 that the mandible rotates backward if the sum of the vertical increases at the facial sutures and the alveolar process exceeds the vertical increases at the mandibular condyle. We inferred that the signicantly increased ANB angles were reected in the reduced prognathism of the mandibular alveolar bone (SNB) after treatment in our study, although there was no signicant difference in the amount of reduction. Many other studies of cephalometric changes with anterior open-bite treatment in the permanent dentition have yielded such ndings as extrusion1,2,1214 and retroclination1,2,11,12,14 of the maxillary central incisors, extrusion14 and uprighting13,14 of the maxillary premolars, uprighting of the maxillary rst molar,10,13,14 extrusion1,2,1014 and retroclination1012,14 of the mandibular central incisors, extrusion12,14 and uprighting13,14 of the mandibular rst premolars, and extrusion1,12,14 and uprighting1,12,14 of the mandibular rst molars. In the present study, both groups also exhibited these changes signicantly. In our study, the most interesting ndings were obtained after the active orthodontic treatment. To be specic, retrusion and extrusion of the maxillary incisors, distal movement of the maxillary rst molars, uprighting of the maxillary rst premolars and the mandibular rst molars were greater in group 1 than in group 2. Moreover, the maxillary rst molars intruded signicantly in group 1 but extruded insignicantly in group 2. We presumed that the extraction of the maxillary second molars in group 1 must have eliminated the posterior discrepancies effectively, and that the MEAW therapy must have forced the maxillary rst molars to move distally and the maxillary rst premolar to tip distally. As a consequence, the area of intercuspal contact between the maxillary and mandibular rst molars must

have decreased, thus giving rise to the distal tipping of the mandibular rst molars being greater in group 1 than in group 2. The distal movement of the maxillary rst molars in group 1 must have hastened the extrusion of the maxillary central incisors. Richardson and Richardson15 reported that in anterior open-bite treatment, extraction of maxillary and mandibular second molars permits overbites to progress as compared with nonextraction. This observation ties in with our ndings that the maxillary central incisors extruded signicantly and that overbites became deeper, though not signicantly, in group 1 than in group 2. The report by Waters and Harris17 that the extraction of maxillary second molars without a headgear causes the rst molars to effectively move in the distal direction also supports our nding about group 1. The results of the present study that the ANS-Me distance increased in groups 1 and 2 alike tallies with the ndings of many preceding studies on anterior open-bite treatment in the permanent dentition,1,2,12 but conicts with the observations by Kim et al.10 that anterior facial height remain unchanged with MEAW therapy. This is probably because Kim et al.10 did not refer to the mesiodistal intermaxillary relations in the cases used for their study nor distinguish extractions from nonextractions of premolars and molars. Our ndings indicated that by MEAW therapy the lower facial height increased with increases in occlusal vertical dimensions in the areas of the maxillary and mandibular rst premolars and molars, resulting in backward and downward rotations of the mandible. These ndings are in agreement with the statement by Isaacson et al.22 to the effect that if the mandible rotates backward, the lower facial height will increase. Extraction of maxillary second molars, as well as nonextraction, can thus be chosen as an effective operating procedure for open-bite correction in the permanent dentition. The present study dealt only with dentofacial morphological changes based on measurements taken from cephalometric radiographs before and after active orthodontic treatment. Additional studies should be done regarding the stability of MEAW therapy during and after the retention period. Further research into this theme will enable us to gain a new insight into the important factors responsible for the relapse of malocclusion after correction.

References
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