CASE REPORT Strategic maxillary second-molar extraction in Class II malocclusion Marcos Roberto de Freitas, a Darwin Vaz de Lima, b Karina Maria Salvatore de Freitas, b Guilherme Janson, a and Jose ´ Fernando Castanha Henriques a Bauru, Sa˜o Paulo, Brazil Maxillary second-molar extraction in Class II malocclusion is a controversial issue in orthodontics. This treat- ment protocol is rigorous and not routine. In this case report, we present the orthodontic treatment of a patient with a Class II malocclusion, maxillary crowding, and no mandibular first molars, treated with extraction of the maxillary second molars. The mechanotherapy and indications of maxillary second-molar extraction are discussed. (Am J Orthod Dentofacial Orthop 2009;136:878-86) T he decision of whether to extract teeth in patients with dental crowding requires thorough consid- eration of several factors. One of the most con- troversial issues concerns maxillary second-molar extraction in a Class II malocclusion. 1 Maxillary sec- ond-molar extraction is indicated when the tooth is se- verely damaged, ectopically erupted, or severely rotated; when there is crowding in the tuberosity area; or when there is excessive labial inclination of the max- illary incisors with no spacing, minimal overbite, and the maxillary third molars are in good position with proper size and shape. 1-5 Some advantages have been attributed to maxillary second-molar extraction, includ- ing reduced treatment time, less potential for reopening of extraction sites, and easier distalization of the first molars. 3,6,7 The primary disadvantage of second-molar removal is uncertainty about the final position of third molars. 3,4 The direction and magnitude of facial growth, the eruption path of the third molars, and the patient’s expected cooperation also should be considered. 1,8 In this case report, we present the orthodontic treat- ment of a patient with a Class II malocclusion, maxil- lary crowding, and no mandibular first molars, treated with extraction of the maxillary second molars. The mechanotherapy and indications of maxillary second- molar extraction are discussed. DIAGNOSIS A 19-year-old woman came for orthodontic treat- ment to the private orthodontic office of the second au- thor (D.V.L) at Cuiaba ´, Mato Grosso, Brazil. Her chief complaint was maxillary incisor crowding. Clinically, she had acceptable facial balance and unstrained lip clo- sure (Fig 1). She had a full-cusp Class II molar and ca- nine relationship, maxillary anterior crowding, and increased overjet and overbite (Fig 2). The mandibular first molars were absent, and the maxillary and mandib- ular third molars were in favorable positions. She had a severe Class II skeletal relationship, and the maxillary and mandibular incisors were linearly well positioned and palatally tipped. The soft-tissue profile was convex (Figs 3 and 4, Table). TREATMENT OBJECTIVES The treatment objectives consisted of correcting the Class II relationship, the maxillary anterior crowding, and overjet and overbite to improve the soft-tissue profile. TREATMENT ALTERNATIVES One treatment option consisted of nonextraction therapy, with space opening for the mandibular first mo- lars for implant replacement. This treatment option seemed viable, but it would produce bimaxillary dental protrusion, and the resulting soft-tissue profile would be unsatisfactory. The second option was extracting the maxillary first premolars and retracting the anterior teeth. However, the patient was afraid that the extraction sites could be temporarily unesthetic and was unwilling to wear bonded pontics in the extraction spaces. The third treatment option included extraction of the maxillary second molars, subsequent distalization of the From the Department of Orthodontics, Bauru Dental School, University of Sa ˜o Paulo, Bauru, Sa ˜o Paulo, Brazil. a Professor. b Postgraduate student. The authors report no commercial, proprietary, or financial interest in the prod- ucts or companies described in this article. Reprint requests to: Marcos Roberto de Freitas, Department of Orthodontics, Bauru Dental School, University of Sa ˜o Paulo, Al. Octa ´vio Pinheiro Brisolla, 9-75, Cep 17012-901, Bauru, SP, Brazil; e-mail, mc.freit@uol.com.br . Submitted, June 2007; revised and accepted, August 2007. 0889-5406/$36.00 Copyright Ó 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.08.039 878