Maxillary premolars extraction or molar distalization with or without TADs: cephalometric evaluation of soft tissue changes in Class II treatment

  • Lorenz Moser Private practice in Bolzano, Deptartment of Orthodontics, University of Ferrara
  • Enrica Di Lorenzo Private practice in Milan, Deptartment of Medicine and Surgery, University of Insubria, Varese
  • Marco Serafin Dept. of Medicine and Surgery, University of Insubria, Varese, Italy
  • Giuliano Maino Private practice in Vicenza, Deptartment of Medicine and Surgery, University of Insubria, Varese
  • Ute Schneider-Moser Private practice in Bolzano, Deptartment of Orthodontics, University of Ferrara, Ferrara
  • Mauro Cozzani United Campus of Malta
  • Alberto Caprioglio Deptartment of Medicine and Surgery, University of Insubria, Varese


Introduction: Problem solving in Class II malocclusion treatment performed with premolars extractions or distalizing techniques in relation to the profile modification.

Aim: To cephalometrically compare soft tissue changes produced either by maxillary premolar extraction, tooth-borne Pendulum appliance or bone-borne MGBM appliance.

Materials and Methods: Both pre- (T1) and post-treatment (T2) lateral cephalograms of 89 skeletal Class II patients (36 M, 53 F), treated during pubertal growth spurt, were retrospectively selected. Three groups were formed based on the therapy performed: 30 patients had been treated with maxillary first premolars extraction (U4), 31 patients with a conventional tooth-borne distalizing with Pendulum appliance (PA), and 28 patients with a skeletally anchored distalizing appliance (MGBM). Soft tissue was analyzed comparing upper (UL) and lower (LL) lip’s points with regard to True Vertical Line (TVL) and Esthetic plane (E-plane). Skeletal and dental values have been recorded in order to cephalometrically compare ΔT2-T1 changes among groups and to correlate dental and skeletal changes to profile modifications. One-way ANOVA was employed to compare groups at T1. Paired sample t-tests were employed to assess significant intra- and intergroup differences between T2 and T1. Significance level was set at 0.05

Results: UL and LL showed a slight but not significant retrusion relative to TVL in all three groups. UL and LL distances to E-plane were not statistically significant among U4, PA, and MGBM groups. Independently of the treatment, UL was tangent to TVL in all groups. No statistically significant differences have been shown in skeletal records. Significant differences were recorded in Overjet among U4 than PA and MGBM groups.

Conclusions: Class II malocclusion treatment with maxillary first premolar extraction, conventional or skeletal distalization did not significantly affect the profile producing similar changes in the soft tissue.


Roos N. Soft-tissue profile changes in class II treatment. Am J Orthod. 1977; 72: 165-75.

Hodges A, Rossouw PE, Campbell PM, Boley JC, Alexander RA, Buschang PH. Prediction of lip response to four first premolar extractions in white female adolescents and adults. Angle Orthod. 2009; 79: 413-21.

Flores-Mir C, Major MP, Major PW. Soft tissue changes with fixed functional appliances in Class II division 1. Angle Orthod. 2006; 76: 712-20.

D’Antò V, Bucci R, Franchi L, Rongo R, Michelotti A, Martina R. Class II functional orthopaedic treatment: a systematic review of systematic reviews. J Oral Rehabil. 2015; 42: 624-42.

Sambataro S, Fastuca R, Oppermann NJ, Lorusso P, Bacetti T, Franchi L, Caprioglio A. Cephalometric changes in growing patients with increased vertical dimension treated with cervical headgear. J Orofac Orthop. 2017; 78: 312-20.

Ghosh J, Nanda RS. Evaluation of an intraoral maxillary molar distalization technique. Am J Orthod Dentofacial Orthop. 1996; 110: 639-46.

Janson G, Brambilla Ada C, Henriques JF, de Freitas MR, Neves LS. Class II treatment success rate in 2- and 4-premolar extraction protocols. Am J Orthod Dentofacial Orthop. 2004; 125: 472-9.

Pancherz H, Ruf S, Erbe C, Hansen K. The mechanism of Class II correction in surgical orthodontic treatment of adult Class II, division 1 malocclusions. Angle Orthod. 2004; 74: 800-9.

Pisani L, Bonaccorso L, Fastuca R, Spena R, Lombardo L, Caprioglio A. Systematic review for orthodontic and orthopedic treatments for anterior open bite in the mixed dentition. Prog Orthod. 2016; 17: 28.

Janson G, Fuziy A, de Freitas MR, Castanha Henriques JF, de Almeida RR. Soft-tissue treatment changes in Class II Division 1 malocclusion with and without extraction of maxillary premolars. Am J Orthod Dentofacial Orthop. 2007; 132: 729.e1-e8.

Caprioglio A, Comaglio I, Siani L, Fastuca R. Effects of impaction severity of treated palatally displaced canines on periodontal outcomes: a retrospective study. Prog Orthod. 2019; 20: 5.

Hilgers JJ. The pendulum appliance for Class II non-compliance therapy. J Clin Orthod. 1992; 26: 706-14.

Bussick TJ, McNamara JA Jr. Dentoalveolar and skeletal changes associated with the pendulum appliance. Am J Orthod Dentofacial Orthop. 2000; 117: 333-43.

Maino BG, Gianelly AA, Bednar J, Mura P, Maino G. MGBM system: new protocol for Class II non extraction treatment without cooperation. Prog Orthod. 2007; 8: 130-43.

Mariani L, Maino G, Caprioglio A. Skeletal versus conventional intraoral anchorage for the treatment of class II malocclusion: dentoalveolar and skeletal effects. Prog Orthod. 2014; 15: 43.

Janson G, Mendes LM, Junqueira CH, Garib DG. Soft-tissue changes in Class II malocclusion patients treated with extractions: a systematic review. Eur J Orthod. 2016; 38: 631-7.

de Almeida-Pedrin RR, Henriques JF, de Almeida RR, de Almeida MR, McNamara JA Jr. Effects of the pendulum appliance, cervical headgear, and 2 premolar extractions followed by fixed appliances in patients with Class II malocclusion. Am J Orthod Dentofacial Orthop. 2009; 136: 833-42.

Pinzan-Vercelino CR, Janson G, Pinzan A, de Almeida RR, de Freitas MR, de Freitas KM. Comparative efficiency of Class II malocclusion treatment with the pendulum appliance or two maxillary premolar extractions and edgewise appliances [corrected]. Eur J Orthod. 2009; 31: 333-40.

McNamara JA Jr, Franchi L. The cervical vertebral maturation method: A user’s guide. Angle Orthod. 2018; 88: 133-43.

Byloff FK, Darendeliler MA. Distal molar movement using the pendulum appliance. Part 1: Clinical and radiological evaluation. Angle Orthod. 1997; 67: 249-60.

Maino G, Mariani L, Bozzo I, Maino G, Caprioglio A. Maxillary molar distalization with MGBM-system in class II malocclusion. J Orthod Sci. 2013; 2: 101-8.

Sarver DM. Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and treatment planning. Am J Orthod Dentofacial Orthop. 2015; 148: 380-6.

Scott Conley R, Jernigan C. Soft tissue changes after upper premolar extraction in Class II camouflage therapy. Angle Orthod. 2006; 76: 59-65.

Kim K, Choi SH, Choi EH, Choi YJ, Hwang CJ, Cha JY. Unpredictability of soft tissue changes after camouflage treatment of Class II division 1 malocclusion with maximum anterior retraction using miniscrews. Angle Orthod. 2017; 87: 230-8.

Atik E, Akarsu-Guven B, Kocadereli I. Soft tissue effects of three different Class II/1-camouflage treatment strategies. J Orofac Orthop. 2017; 78: 153-65.

Fontana M, Cozzani M, Caprioglio A. Non-compliance maxillary molar distalizing appliances: an overview of the last decade. Prog Orthod. 2012; 13: 173-84.

Mohamed RN, Basha S, Al-Thomali Y. Maxillary molar distalization with miniscrew-supported appliances in Class II malocclusion: A systematic review. Angle Orthod. 2018; 88: 494-502.

Lee YJ, Park JT, Cha JY. Perioral soft tissue evaluation of skeletal Class II Division 1: A lateral cephalometric study. Am J Orthod Dentofacial Orthop. 2015; 148: 405-13.

Maetevorakul S, Viteporn S. Factors influencing soft tissue profile changes following orthodontic treatment in patients with Class II Division 1 malocclusion. Prog Orthod. 2016; 17: 13.

James RD. A comparative study of facial profiles in extraction and nonextraction treatment. Am J Orthod Dentofacial Orthop. 1998; 114: 265-76.

Bishara SE, Jacobsen JR, Hession TJ, Treder JE. Soft tissue profile changes from 5 to 45 years of age. Am J Orthod Dentofacial Orthop. 1998; 114: 698-706.

20. Caprioglio A, Fontana M, Longoni E, Cozzani M. Long-term evaluation of the molar movements following Pendulum and fixed appliances. Angle Orthod. 2013; 83: 447-54.

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