ORIGINAL ARTICLE
Extraction vs no treatment: Long-term facial profile changes Anita Bhavnani Rathod,a Eustaquio Araujo,b James L. Vaden,c Rolf G. Behrents,d and Donald R. Olivere Yorba Linda, Calif, St Louis, Mo, and Cookeville, Tenn
Introduction: Long-term soft tissue response to extraction orthodontic treatment has been a subject of interest for years. The purposes of this study were to investigate long-term soft tissue profile changes in an extraction sample and to compare them with profile changes in an untreated sample. Methods: A premolar extraction– treated sample (n 5 47) and an untreated control sample (n 5 57) were studied. Descriptive statistics were collected, and individual t tests were used for comparison and contrast of the treated and untreated samples. Results: We found that the untreated soft tissue profile changed in the downward and forward direction. The treated soft tissue profile change was similar, but with more of a forward component than in the untreated sample. Most noteworthy was the finding that the soft tissue profiles of both the untreated and the treated samples were similar at the end point. Conclusions: The following conclusions were derived from the study. (1) There was no substantive difference in the soft tissue profiles of the samples, but there were some differences in the directional changes between them. (2) The changes for the untreated sample were the greatest for the lips and the chin, with the change occurring in the downward and forward direction. (3) The soft tissue profiles of the extraction sample also had the greatest measurable changes in the lips and the chin, but the changes had more of a forward component than they did in the untreated sample. (4) Extraction treatment does not adversely impact soft tissue profile changes over time. (Am J Orthod Dentofacial Orthop 2015;147:596-603)
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acial esthetic ideals were documented as early as 4 BC by the Greeks and were studied by the Egyptians, Romans, and Italians.1 Many ideas that surround the correction of the irregularities of teeth were first published in Britain by Kingsley in 1880, but the author did not address the relationship between esthetics and orthodontics.2 In 1900, Angle formally established orthodontics as a dental specialty and insisted that patients whose full complement of teeth was maintained would have superior occlusions.3 He was one of the first to define a relationship between orthodontics and facial esthetics. Angle4 strongly believed that once a superior occlusion was achieved, excellent facial esthetics would be the result. Tweed5 challenged
a
Private practice, Yorba Linda, Calif. Pete Sotiropoulos professor of orthodontics and clinic director, Orthodontic Graduate Program, Saint Louis University, St Louis, Mo. c Private practice, Cookeville, Tenn. d Professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. e Professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: James L. Vaden, 308 E First St, Cookeville, TN 38501; e-mail, [email protected]. Submitted, July 2012; revised and accepted, January 2015. 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2015.01.018 b
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Angle's concepts solely on esthetic grounds. He documented the fact that a normal complete dentition occlusion does not always predispose the patient to ideal facial balance. Tweed recognized that facial balance and harmony could not be achieved because many patients who were treated without extractions had protrusive lips and faces. He contended that these patients had profiles that were not esthetically pleasing because the teeth were too far forward. Over the years, cephalometric “norms” have been defined by the specialty.6-10 The effect of growth on the soft tissue profile began to be addressed by investigators who detailed changes due to growth alone.11-22 In 1985, Behrents11 documented long-term soft tissue changes in an untreated sample. He studied subjects from the Bolton-Brush growth series; many were in their 60s and 70s when recalled. The following changes in the facial profiles of these untreated patients were found. (1) There was an increase in nasal projection. The nasal tip moved inferiorly. (2) Both lips became less prominent and tended to move inferiorly. The upper lip tended to move down and back, and this led to less exposure of the maxillary teeth. (3) The nasolabial angle became more acute. Essentially, Behrents found and described a clockwise rotation of the nasolabial complex. Recently, there has been debate on both sides of the issue of where teeth should be left during adolescent
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treatment to compensate for these documented changes that occur in the aging face. The extractionnonextraction debate is flourishing again. In 1994, Proffit23 looked at changes in the extraction rate over the previous 40-year period. He estimated that the extraction rates were 30% in 1953, 76% in 1968, and 28% in 1993. Sarver et al24 contended that teeth should be left in a forward position because of the changes that will occur to the face. Specifically, they stated, “First, in designing treatment for the adolescent, the orthodontist usually is the first professional to make decisions on how a patient will look for the rest of his or her life. For instance, anterior teeth that were retracted in adolescence to correct a protrusion, even though they looked good initially, may appear overretracted 20 years later. The experience in the 1950s and 1960s of high extraction rates and profile flattening has resulted in many unesthetic facial outcomes. For these patients, there is loss of lip thickness with aging which makes the lack of lip support from the teeth even more obvious.” As a result of this expressed and valid concern, numerous published studies have documented changes in the soft tissue profile after both extraction and nonextraction orthodontic treatments.25-42 Luppanapornlarp and Johnston43 studied samples of “clear-cut” extraction and nonextraction patients. They found that the patients treated without extractions in fact had the flattest faces in their sample. Cloward44 went a step farther and studied the impact of 4 first premolar extractions on the facial profiles of patients with minimal crowding. As expected, Cloward found profile changes in those subjects. Zierhut et al45 determined that when the faces of a Class II Division 1 extraction treatment sample were compared with the faces of a Class II Division 1 nonextraction sample, they are similar. Even more interesting was that after 14 years, the faces in the sample of Zierhut et al, although they had flattened somewhat, remained similar. The changes were, therefore, maturational and had nothing to do with the extractions or the lack thereof. This study was initiated to find some answers to these seemingly continual questions. It was completed in an attempt to help solve the controversy of what impact, if any, extractions have on the aging face. MATERIAL AND METHODS
A sample of 57 untreated subjects was selected from the Bolton-Brush study at Case Western Reserve University in Cleveland, Ohio. The search on the Bolton database focused on subjects who had cephalometric films taken between 10 and 17 years of age and again after 30 years of age. These age groups were selected in
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an attempt to match the 10- to 17-year posttreatment films of the extraction sample to the sample that had received no treatment. The sole inclusion criterion (aside from high-quality cephalometric films with discernible soft tissue profiles) was that no subject had received orthodontic treatment. Films were chosen consecutively until no more persons met the inclusion criterion. The subjects in the Bolton-Brush sample had Angle Class I, Class II, or Class III malocclusions. Each subject was included in the study because his or her facial profile at 10 to 17 years of age matched the posttreatment profiles of the patients in the treated sample. A sample of 47 orthodontic patients was selected from a collection of files of patients who were recalled approximately 25 years after their premolar extraction treatment was completed. Of these patients, 31 had Angle Class II malocclusions, 15 had Angle Class I malocclusions, and 1 had an Angle Class III malocclusion. All treated patients had extractions before treatment to ameliorate crowding, reduce facial protrusion, facilitate Class II dentition correction, or accomplish a combination of any of these goals. The films were chosen consecutively until there were no more patients who met the criteria. To meet the inclusion criteria, the patient needed to have high-quality cephalometric films taken after treatment and again nearly 25 years later. As with the untreated sample films, all had to show good soft tissue definitions and contain all landmarks necessary for analysis. Films were chosen consecutively until there were no more patients who met the criteria. All patients in the treated sample had 4 teeth extracted before orthodontic treatment. The premolar extractions were in the following patterns: 4 first premolars, 4 second premolars, maxillary first premolars and mandibular second premolars, or 3 premolars and a badly decayed first molar. Most important is that all were treated in a private practice by the same clinician (J.L.V.), who had similar treatment objectives for all patients who were included in the sample. Statistical analysis
Hard and soft tissue anatomic landmarks initially established by Barnette46 were traced for each film. The landmarks were traced for the untreated and treated samples at both time points and then digitized using Dentofacial Planner software (version 7.0; Dentofacial Planner, Toronto, Ontario, Canada). In this software, 2 reference planes were constructed to create an x-y coordinate grid: a horizontal line was created level with nasion at an angle parallel to the sella-nasion line minus 7 , and a vertical line was created perpendicular to the
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Table I. Landmarks
Fig 1. Reference planes (modified from Barnette46).
parallel line to the sella-nasion line minus 7 passing through sella. These planes are shown in Figure 1. Descriptive data were obtained, and a statistical analysis was performed using the Statistical Package for the Social Sciences (version 18; SPSS, Chicago, Ill). Descriptive statistics and variable analyses were calculated for 14 landmarks. Facial measurements, soft tissue thicknesses, and soft tissue lengths were also analyzed (Table I). The landmarks used for this study are illustrated in Figure 2. Independent t tests were performed with a set significance level of P \0.05 to appraise the changes in position of the 14 landmarks and to ascertain the changes in facial measurements, soft tissue thicknesses, and soft tissue lengths. The percentages of enlargement were considered for both samples. Mellion47 had previously determined that specific films from the extraction group nearly 25 years after treatment had a reduction in magnification. This was due to the use of a different cephalostat and the consequent reduction in the object to film distance. All films from the Bolton study were produced with the Bolton cephalometric technique, in which there was a constant anode to object distance of 5 feet, and the object to film distance, also called the midline to lateral film distance, was kept to a minimum.48 The midline to lateral film value is therefore unique for each patient and also unique to each film. The midline to lateral film distance was recorded for each film traced and then converted to the percentage of enlargement from the Bolton standard technique. Once all enlargement values were identified, a conversion factor was found from the effect of distance from the subject to the film.49 All distances were adjusted to 0% enlargement (ie, life size). Microsoft
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Abbreviation Na Na0 Rhn Rhn0 Prn Int Sbn Sls Ls Li Lmf Pog Pog0 Me Me0 A B U1 L1
Cephalometric point Nasion Soft tissue nasion Rhinion Soft tissue rhinion Pronasale Inferior nasal tip Subnasale Superior labial sulcus Labrale superius Labrale inferius Labiomental fold Pogonion Soft tissue pogonion Menton Soft tissue menton A-point B-point Maxillary incisor tip Mandibular incisor tip
Fig 2. Landmarks shown in Table I used in analysis (modified from Barnette46).
Word and Excel from Microsoft Office (edition 2007; Microsoft, Redmond, Wash) were used for the construction of tables and graphs. Profile images detailing the soft tissue changes for the descriptive statistics of each sample were created using Adobe Illustrator (version CS11; Adobe, San Jose, Calif). RESULTS
The study was designed to determine whether there is a significant difference in the soft tissue facial
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Table II. Comparison of posttreatment differences and 251 years posttreatment differences for the untreated and extraction-treated samples Measurement x Prn y Prn x Int y Int x Sls y Sls x Ls y Ls x Li y Li x Lmf y Lmf x Pog0 y Pog0 x Me0 y Me0 x A-point y A-point x U1 y U1 x L1 y L1 x B-point y B-point x Pog y Pog x Me y Me
Untreated, mean 6 SD (mm) 7.62 6 5.38 1.74 6 5.15 7.31 6 5.50 2.14 6 5.09 5.68 6 5.67 3.61 6 4.92 4.88 6 6.53 5.27 6 5.18 8.45 6 7.17 1.47 6 5.95 9.96 6 7.96 4.69 6 5.90 11.62 6 9.08 6.38 6 6.53 11.62 6 10.16 7.42 6 7.18 7.20 6 5.23 2.53 6 4.62 8.21 6 6.44 1.99 6 4.80 7.79 6 6.30 2.53 6 5.00 8.68 6 7.82 3.16 6 5.76 10.38 6 8.77 5.19 6 6.72 10.48 6 9.25 5.62 6 6.88
Extraction-treated, mean 6 SD (mm) 4.32 6 5.28 1.13 6 4.45 4.42 6 5.64 0.08 6 4.00 3.39 6 7.39 1.19 6 3.86 3.80 6 8.28 1.86 6 3.76 3.38 6 9.32 1.92 6 4.06 8.57 6 10.03 0.03 6 4.78 11.13 6 11.45 1.83 6 5.44 12.67 6 12.20 1.05 6 4.41 4.50 6 6.54 0.22 6 3.42 6.86 6 9.21 0.49 6 3.21 6.23 6 8.93 0.69 6 3.54 8.26 6 10.27 0.12 6 4.34 10.05 6 11.77 0.65 6 4.34 10.49 6 12.24 1.09 6 4.42
t 3.16 3.06 2.64 3.36 1.33 2.83 0.75 3.90 1.25 3.45 0.78 4.48 0.24 3.89 0.45 5.58 2.30 2.95 0.89 1.92 1.02 3.87 0.23 3.32 0.16 4.18 0.00 4.09
Significance (2-tailed) 0.002* 0.003* 0.010* 0.001* 0.187 0.006* 0.468 0.000* 0.214 0.001* 0.439 0.000* 0.813 0.000* 0.657 0.000* 0.024* 0.004* 0.396 0.058 0.311 0.000* 0.820 0.001* 0.872 0.000* 1.000 0.000*
x, horizontal; y, vertical. *P #0.05.
profiles of adults who did not undergo orthodontic treatment compared with the profiles of patients who had extraction orthodontic treatment as teens. This study is relevant and important, particularly in our society that believes in nonextraction at all costs. We hope that it will give our specialty some useful and important information about the long-term impact of extraction treatment on the facial profile. Independent t test comparisons between the untreated and extraction-treated samples at posttreatment and recall are shown in Table II. The differences were significant for horizontal and vertical pronasale, horizontal and vertical inferior nasal tip, vertical superior labial sulcus, vertical labrale superius, vertical labrale inferius, vertical labiomental fold, vertical soft tissue pogonion, vertical soft tissue menton, horizontal and vertical A-point, vertical mandibular incisor tip, vertical B-point, vertical pogonion, and vertical menton. For all landmarks that had significance, the changes were greater in the untreated sample, but the direction of change was more horizontal than vertical in the treated sample.
Independent t tests were performed to ascertain the significant differences between posttreatment and recall for the untreated and the extraction-treated samples. Results for facial measurements, soft tissue thicknesses, and soft tissue lengths are given in Tables III-V. For the facial measurements (Table III), the changes in hard tissue facial angle, nasolabial angle, mentolabial fold, and upper and lower anterior facial height were significantly different. The hard tissue facial convexity angle changed more in the extraction-treated sample and became less convex. The nasolabial angle and the mentolabial angle changed more in the untreated sample and became less convex. The upper and lower anterior facial heights changed more in the untreated sample and became larger. Soft tissue thickness differences (Table IV) between posttreatment and recall were compared. Rhinion and B-point in the untreated sample changed more and became thicker than in the extraction-treated sample. Soft tissue length (Table V) changed significantly over the time interval studied. Upper and lower lips and nose lengths changed significantly more in
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Table III. Comparison of posttreatment and 251 years posttreatment facial measurement differences Facial measurement Na0 -Prn-Pog0 ( ) Na–A-point–Pog ( ) (reference to 180 ) Int-Sbn-Ls ( ) Li-Lmf-Pog0 ( ) (reference to 180 ) Na0 -Sbn (mm) Sbn-Me0 (mm)
Untreated, mean 6 SD (mm) 1.81 6 5.03 1.60 6 11.37 4.44 6 8.54 22.89 6 26.26 3.22 6 3.31 3.69 6 4.87
Extraction-treated, mean 6 SD (mm) 1.49 6 4.10 5.39 6 7.52 0.96 6 7.29 0.15 6 14.68 0.73 6 2.32 1.21 6 3.48
Significance (2-tailed) 0.72 0.046* 0.026* 0.000* 0.000* 0.000*
t 0.36 2.03 2.25 5.6 4.52 6
*P #0.05.
IV. Comparison of posttreatment and 251 years posttreatment soft tissue thickness differences
Table
Untreated, Soft tissue mean 6 thickness (mm) SD (mm) Rhn-Rhn0 0.37 6 0.86 A-point–Sls 0.76 6 3.39 B-point–Lmf 1.43 6 1.59 Pog-Pog0 1.48 6 1.97
Extractiontreated, mean 6 Significance SD (mm) t (2-tailed) 0.04 6 0.95 2.31 0.023* 0.1 6 2.68 1.1 0.274 0.31 6 1.16 4.18 0.000* 0.93 6 1.94 1.44 0.154
Table V. Comparison of posttreatment and 251 years
posttreatment soft tissue length differences
Soft tissue length (mm) Sbn-Ls Lmf-Li Na0 -Prn
Untreated, mean 6 SD (mm) 3.91 6 3.22 1.44 6 2.11 4.85 6 3.91
Extractiontreated, mean 6 SD (mm) 2.23 6 1.70 0.24 6 2.17 1.76 6 2.78
t 3.44 2.87 4.72
Significance (2-tailed) 0.001* 0.005* 0.000*
*P #0.05.
*P #0.05.
the untreated sample than in the extraction-treated sample. Figure 3 is a visual representation of the changes from posttreatment to recall for the untreated and extraction-treated samples. DISCUSSION
Craniofacial growth and changes in the adult craniofacial complex began to be studied in the 1970s. Israel50,51 ascertained that the craniofacial complex increased in size well into adulthood. He postulated that this increase was a consequence of remodeling, not sutural expansion. Susanne52,53 studied the cephalograms of 44 subjects who were measured twice between the ages of 25 and 60 years. He found increases in the length and the breadth of the head. He found increases in nasion to stomion height and in facial height. He concluded that growth continued into the fourth and even into the sixth decade of life. State-of-the-art studies of the cranial and facial changes during adulthood were done by Behrents.11 His findings, previously described, were consistent with what was found in the untreated sample. Although the age range of the Bolton-Brush subjects studied by Behrents, who were also used as the untreated sample in this study, was greater than the age range of the treated subjects, the results of the study are the same
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as they would have been had the untreated age range been closer to that of the treated sample. This statement can be made because Behrents found that the skeletal and soft tissue changes during the fifth and sixth decades of life were small. The untreated sample showed the greatest changes for hard and soft tissue pogonion and menton. Although the change was large in the horizontal direction, it also had a significant vertical component. A moderate amount of change in the horizontal direction was seen in the untreated sample for labiomental fold, Point B, labrale inferius, mandibular incisor tip, maxillary incisor tip, Point A, pronasale, and inferior nasal tip. A moderate amount of vertical change in the untreated sample was seen in labiomental fold, Point B, mandibular incisor tip, maxillary incisor tip, Point A, and inferior nasal tip. All landmarks with a moderate horizontal change also showed a moderate vertical change, except for maxillary incisor tip, labrale inferius, and pronasale. Superior labial sulcus and labrale superius showed small amounts of horizontal change, but the superior labial sulcus had a moderate vertical change, whereas labrale superius had a large vertical component change. Labrale inferius, maxillary incisor tip, and pronasale all showed small vertical changes. Landmark changes for the untreated and extraction samples had both vertical and horizontal components. A moderate horizontal change was seen in labiomental fold and B-point. These landmarks also showed a small
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Fig 3. Changes from posttreatment to recall for the untreated sample (left) and extraction-treated sample (right).
Fig 4. Ricketts' E-plane at posttreatment for the untreated (black line) and extraction-treated (red line) samples.
Fig 5. Ricketts' E-plane at 251 years posttreatment for the untreated (black line) and extraction-treated (red line) samples.
vertical component. Small amounts of horizontal and vertical changes were seen for labrale inferius, mandibular incisor tip, maxillary incisor tip, A-point, pronasale, inferior nasal tip, superior labial sulcus, and labrale superius. Interestingly, the vertical components for B-point, labrale inferius, mandibular incisor tip,
pronasale, and inferior nasal tip changed in the upward direction. This study confirmed that mandibular prognathism in an untreated sample increases with age,10,12 as does mandibular prognathism in an extraction-treated sample.27,30,31 MacGilpin et al54 reached a similar conclusion.
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profile. The conclusions drawn from this study are the following. 1. There is no substantive esthetic difference between untreated and extraction-treated samples at a long-term recall evaluation. 2. There are different directional changes for the soft tissue profiles of subjects who were untreated and those treated with extractions. 3. The soft tissue changes for the untreated sample were greatest for the lips and chin. Change was in a downward and forward direction. 4. The soft tissue changes for the extraction-treated sample were generally greatest for the lips and chin. Change was primarily in a forward direction. 5. Extractions do not adversely impact the esthetics of a soft tissue facial profile over time. REFERENCES
Fig 6. Lip and chin changes for the untreated (solid lines) and extraction-treated (dotted lines) samples.
To further evaluate the esthetics of the soft tissue profiles for both the untreated and extraction-treated samples, the E-plane of Ricketts8 was used. Figures 4 and 5 show the E-plane for the posttreatment untreated and extraction-treated samples and for the recalled untreated and extraction-treated samples, respectively. According to Ricketts, the ideal adult lower lip should be located 4 mm behind the E-plane 6 3 mm. The untreated sample at posttreatment had a lower lip to E plane measurement of 2 mm; the treated sample measured 4 mm. At the recall, the untreated lower lip was 5 mm and the treated was 7 mm; both were within Ricketts' acceptable range. Therefore, both samples at posttreatment and recall were considered to be esthetically acceptable. Figure 6 shows changes for the lips and the chin when nasal changes are disregarded. This figure demonstrates that although the lips and chin create different line angles at posttreatment, at recall the samples create similar line angles located close together. This fact further confirms that treatment with extractions does not “flatten” the soft tissue facial profile when the extraction profile is compared with the untreated profile. CONCLUSIONS
This study was designed to provide some evidence about whether the extraction of premolars has significant long-term effects on the esthetics of the soft tissue
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1. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 1970; 40:284-318. 2. Asbell M. Norman W. Kingsley (1928-1913). Am J Orthod Dentofacial Orthop 1999;115:101. 3. Asbell MB. A brief history of orthodontics. Am J Orthod Dentofacial Orthop 1990;98:206-13. 4. Angle EH. The treatment of malocclusion of the teeth. 7th ed. Philadelphia: S. S. White; 1907. 5. Tweed CH. Indications for extraction of teeth in orthodontic procedures. Am J Orthod Surg 1944;30:405-28. 6. Steiner C. Cephalometrics in clinical practice. Am J Orthod 1959; 29:8-29. 7. Casko JS, Shepherd WB. Dental and skeletal variation within the range of normal. Angle Orthod 1984;54:5-17. 8. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod 1968;54:272-89. 9. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod 1984;85: 279-93. 10. Burstone C. Integumental contour and extension patterns. Angle Orthod 1959;9:93-104. 11. Behrents RG. Growth in the aging craniofacial skeleton. Monograph 17. Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1985. 12. Subtelny J. A longitudinal study of soft tissue facial structures and their profile characteristics, defined in relation to underling skeletal structures. Am J Orthod 1959;45:481-507. 13. Forsberg CM. Facial morphology and ageing: a longitudinal cephalometric investigation of young adults. Eur J Orthod 1979;1: 15-23. 14. Sarn€as KV, Solow B. Early adult changes in the skeletal and softtissue profile. Eur J Orthod 1980;2:1-12. 15. Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-tissue profile changes: a study of three analyses. Am J Orthod 1985;88: 209-23. 16. Nanda RS, Meng H, Kapila S, Goorhuis J. Growth changes in the soft tissue facial profile. Angle Orthod 1990;60:177-90. 17. Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop 1994;105: 464-76.
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18. Chaconas SJ, Bartroff JD. Prediction of normal soft tissue facial changes. Angle Orthod 1975;45:12-25. 19. Posen JM. A longitudinal study of the growth of the nose. Am J Orthod 1967;53:746-56. 20. Genecov JS, Sinclair PM, Dechow PC. Development of the nose and soft tissue profile. Angle Orthod 1990;60:191-8. 21. Zankl A, Eberle L, Molinari L, Schinzel A. Growth charts for nose length, nasal protrusion, and philtrum length from birth to 97 years. Am J Med Genet 2002;111:388-91. 22. Bloom L. Perioral profile changes in orthodontic treatment. Am J Orthod 1961;47:371-9. 23. Proffit WR. Forty-year review of extraction frequencies at a university orthodontic clinic. Angle Orthod 1994;64:407-14. 24. Sarver DM, Proffit WR, Ackerman JL. In: Proffit WR, White RP, Sarver DM, editors. Contemporary treatment of dentofacial deformity. St Louis: Mosby; 2003. 25. Rudee DA. Proportional profile changes concurrent with orthodontic therapy. Am J Orthod 1964;50:421-34. 26. Hershey HG. Incisor tooth retraction and subsequent profile change in post adolescent female patients. Am J Orthod 1972; 61:45-54. 27. Anderson JP, Joondeph DR, Turpin DL. A cephalometric study of profile changes in orthodontically treated cases ten years out of retention. Angle Orthod 1973;43:324-36. 28. Waldman BH. Change in lip contour with maxillary incisor retraction. Angle Orthod 1982;52:129-34. 29. Drobocky OB, Smith RJ. Changes in facial profile during orthodontic treatment with extraction of four first premolars. Am J Orthod Dentofacial Orthop 1989;95:220-30. 30. Paquette DE, Beattie JR, Johnston LE Jr. A long-term comparison of nonextraction and premolar extraction edgewise therapy in “borderline” Class II patients. Am J Orthod Dentofacial Orthop 1992;102:1-14. 31. Binda SK, Kuijpers-Jagtman AM, Maertens JK, van’t Hof MA. A long-term cephalometric evaluation of treated Class II division 2 malocclusions. Eur J Orthod 1994;16:301-8. 32. Bowman SJ, Johnston LE Jr. The esthetic impact of extraction and nonextraction treatments on Caucasian patients. Angle Orthod 2000;70:3-10. 33. Wholley CJ, Woods MG. The effects of commonly prescribed premolar extraction sequences on the curvature of the upper and lower lips. Angle Orthod 2003;73:386-95. 34. Kocadereli I. Changes in soft tissue profile after orthodontic treatment with and without extractions. Am J Orthod Dentofacial Orthod 2002;122:67-72. 35. James RD. A comparative study of facial profiles in extraction and nonextraction treatment. Am J Orthod Dentofacial Orthop 1998; 114:265-76. 36. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial and soft tissue changes in Class II, division I cases treated with and without extractions. Am J Orthod Dentofacial Orthop 1995;107:28-37.
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37. Roos N. Soft-tissue profile changes in Class II treatment. Am J Orthod 1977;72:165-75. 38. Garner LD. Soft-tissue changes concurrent with orthodontic tooth movement. Am J Orthod 1974;66:367-77. 39. Lo FD, Hunter WS. Changes in nasolabial angle related to maxillary incisor retraction. Am J Orthod 1982;82:384-91. 40. Perkins RA, Staley RN. Change in lip vermilion height during orthodontic treatment. Am J Orthod Dentofacial Orthop 1993;103: 147-54. 41. Kasai K. Soft tissue adaptability to hard tissues in facial profiles. Am J Orthod Dentofacial Orthop 1998;113:674-84. 42. Hanson RA. Incisor retraction and lip response with various extraction patterns in Caucasian females [thesis]. St Louis: Saint Louis University; 2003. Accessed April 1, 2014. 43. Luppanapornlarp S, Johnston LE Jr. The effects of premolarextraction: a long-term comparison of outcomes in “clear-cut” extraction and nonextraction Class II patients. Angle Orthod 1993;63:257-72. 44. Cloward DJ. Facial profile changes with extraction of four first premolars in Caucasian, Class I, minimally-crowded, adolescent patients [thesis]. St Louis: Saint Louis University; 2013. Accessed April 1, 2014. 45. Zierhut EC, Joondeph DR, Artun J, Little RM. Long term profile changes associated with successfully treated extraction and nonextraction Class II, Division I malocclusions. Angle Orthod 2000; 70:208-19. 46. Barnette KA. A Longitudinal cephalometric study of the soft tissue profile of male and female orthodontically treated Class I and Class II subjects [thesis]. St Louis: Saint Louis University; 2008. Available at: http://www.slu.edu/Documents/Cade/Thesis/Barnette_Thesis. pdf. Accessed November 4, 2013. 47. Mellion N. A longitudinal, multivariate analysis of orthodontic relapse [thesis]. St Louis: Saint Louis University; 2011. Available at: http://www.slu.edu/Documents/cade/thesis/Mellion_Thesis_ 2010.pdf. Accessed November 4, 2013. 48. Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton standards of dentofacial development growth. St Louis: C. V. Mosby; 1975. 49. Thurow R. Atlas of orthodontic principles. St Louis: C. V. Mosby; 1970. 50. Israel H. Age factor and the pattern of change in craniofacial structures. Am J Phys Anthropol 1973;39:111-28. 51. Israel H. The dichotomous pattern of craniofacial expansion during aging. Am J Phys Anthropol 1977;47:47-52. 52. Susanne C. Individual age changes of the morphological characteristics. J Hum Evol 1977;6:181-9. 53. Susanne C. Aging, continuous changes of adulthood. In: Johnston FE, Roche AF, Susanne C, editors. Human physical growth and maturation. New York: Plenum Press; 1978. p. 111-24. 54. MacGilpin DH, Araujo EA, Behrents RG, Rowan KB. Spatial changes in the relationship of the mandible and maxilla with different extraction patterns and techniques. Angle Orthod 2011;81:584-91.
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Extraction vs no treatment: Long-term facial profile changes Anita Bhavnani Rathod,a Eustaquio Araujo,b James L. Vaden,c Rolf G. Behrents,d and Donald R. Olivere Yorba Linda, Calif, St Louis, Mo, and Cookeville, Tenn
Introduction: Long-term soft tissue response to extraction orthodontic treatment has been a subject of interest for years. The purposes of this study were to investigate long-term soft tissue profile changes in an extraction sample and to compare them with profile changes in an untreated sample. Methods: A premolar extraction– treated sample (n 5 47) and an untreated control sample (n 5 57) were studied. Descriptive statistics were collected, and individual t tests were used for comparison and contrast of the treated and untreated samples. Results: We found that the untreated soft tissue profile changed in the downward and forward direction. The treated soft tissue profile change was similar, but with more of a forward component than in the untreated sample. Most noteworthy was the finding that the soft tissue profiles of both the untreated and the treated samples were similar at the end point. Conclusions: The following conclusions were derived from the study. (1) There was no substantive difference in the soft tissue profiles of the samples, but there were some differences in the directional changes between them. (2) The changes for the untreated sample were the greatest for the lips and the chin, with the change occurring in the downward and forward direction. (3) The soft tissue profiles of the extraction sample also had the greatest measurable changes in the lips and the chin, but the changes had more of a forward component than they did in the untreated sample. (4) Extraction treatment does not adversely impact soft tissue profile changes over time. (Am J Orthod Dentofacial Orthop 2015;147:596-603)
F
acial esthetic ideals were documented as early as 4 BC by the Greeks and were studied by the Egyptians, Romans, and Italians.1 Many ideas that surround the correction of the irregularities of teeth were first published in Britain by Kingsley in 1880, but the author did not address the relationship between esthetics and orthodontics.2 In 1900, Angle formally established orthodontics as a dental specialty and insisted that patients whose full complement of teeth was maintained would have superior occlusions.3 He was one of the first to define a relationship between orthodontics and facial esthetics. Angle4 strongly believed that once a superior occlusion was achieved, excellent facial esthetics would be the result. Tweed5 challenged
a
Private practice, Yorba Linda, Calif. Pete Sotiropoulos professor of orthodontics and clinic director, Orthodontic Graduate Program, Saint Louis University, St Louis, Mo. c Private practice, Cookeville, Tenn. d Professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. e Professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: James L. Vaden, 308 E First St, Cookeville, TN 38501; e-mail, [email protected]. Submitted, July 2012; revised and accepted, January 2015. 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2015.01.018 b
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Angle's concepts solely on esthetic grounds. He documented the fact that a normal complete dentition occlusion does not always predispose the patient to ideal facial balance. Tweed recognized that facial balance and harmony could not be achieved because many patients who were treated without extractions had protrusive lips and faces. He contended that these patients had profiles that were not esthetically pleasing because the teeth were too far forward. Over the years, cephalometric “norms” have been defined by the specialty.6-10 The effect of growth on the soft tissue profile began to be addressed by investigators who detailed changes due to growth alone.11-22 In 1985, Behrents11 documented long-term soft tissue changes in an untreated sample. He studied subjects from the Bolton-Brush growth series; many were in their 60s and 70s when recalled. The following changes in the facial profiles of these untreated patients were found. (1) There was an increase in nasal projection. The nasal tip moved inferiorly. (2) Both lips became less prominent and tended to move inferiorly. The upper lip tended to move down and back, and this led to less exposure of the maxillary teeth. (3) The nasolabial angle became more acute. Essentially, Behrents found and described a clockwise rotation of the nasolabial complex. Recently, there has been debate on both sides of the issue of where teeth should be left during adolescent
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treatment to compensate for these documented changes that occur in the aging face. The extractionnonextraction debate is flourishing again. In 1994, Proffit23 looked at changes in the extraction rate over the previous 40-year period. He estimated that the extraction rates were 30% in 1953, 76% in 1968, and 28% in 1993. Sarver et al24 contended that teeth should be left in a forward position because of the changes that will occur to the face. Specifically, they stated, “First, in designing treatment for the adolescent, the orthodontist usually is the first professional to make decisions on how a patient will look for the rest of his or her life. For instance, anterior teeth that were retracted in adolescence to correct a protrusion, even though they looked good initially, may appear overretracted 20 years later. The experience in the 1950s and 1960s of high extraction rates and profile flattening has resulted in many unesthetic facial outcomes. For these patients, there is loss of lip thickness with aging which makes the lack of lip support from the teeth even more obvious.” As a result of this expressed and valid concern, numerous published studies have documented changes in the soft tissue profile after both extraction and nonextraction orthodontic treatments.25-42 Luppanapornlarp and Johnston43 studied samples of “clear-cut” extraction and nonextraction patients. They found that the patients treated without extractions in fact had the flattest faces in their sample. Cloward44 went a step farther and studied the impact of 4 first premolar extractions on the facial profiles of patients with minimal crowding. As expected, Cloward found profile changes in those subjects. Zierhut et al45 determined that when the faces of a Class II Division 1 extraction treatment sample were compared with the faces of a Class II Division 1 nonextraction sample, they are similar. Even more interesting was that after 14 years, the faces in the sample of Zierhut et al, although they had flattened somewhat, remained similar. The changes were, therefore, maturational and had nothing to do with the extractions or the lack thereof. This study was initiated to find some answers to these seemingly continual questions. It was completed in an attempt to help solve the controversy of what impact, if any, extractions have on the aging face. MATERIAL AND METHODS
A sample of 57 untreated subjects was selected from the Bolton-Brush study at Case Western Reserve University in Cleveland, Ohio. The search on the Bolton database focused on subjects who had cephalometric films taken between 10 and 17 years of age and again after 30 years of age. These age groups were selected in
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an attempt to match the 10- to 17-year posttreatment films of the extraction sample to the sample that had received no treatment. The sole inclusion criterion (aside from high-quality cephalometric films with discernible soft tissue profiles) was that no subject had received orthodontic treatment. Films were chosen consecutively until no more persons met the inclusion criterion. The subjects in the Bolton-Brush sample had Angle Class I, Class II, or Class III malocclusions. Each subject was included in the study because his or her facial profile at 10 to 17 years of age matched the posttreatment profiles of the patients in the treated sample. A sample of 47 orthodontic patients was selected from a collection of files of patients who were recalled approximately 25 years after their premolar extraction treatment was completed. Of these patients, 31 had Angle Class II malocclusions, 15 had Angle Class I malocclusions, and 1 had an Angle Class III malocclusion. All treated patients had extractions before treatment to ameliorate crowding, reduce facial protrusion, facilitate Class II dentition correction, or accomplish a combination of any of these goals. The films were chosen consecutively until there were no more patients who met the criteria. To meet the inclusion criteria, the patient needed to have high-quality cephalometric films taken after treatment and again nearly 25 years later. As with the untreated sample films, all had to show good soft tissue definitions and contain all landmarks necessary for analysis. Films were chosen consecutively until there were no more patients who met the criteria. All patients in the treated sample had 4 teeth extracted before orthodontic treatment. The premolar extractions were in the following patterns: 4 first premolars, 4 second premolars, maxillary first premolars and mandibular second premolars, or 3 premolars and a badly decayed first molar. Most important is that all were treated in a private practice by the same clinician (J.L.V.), who had similar treatment objectives for all patients who were included in the sample. Statistical analysis
Hard and soft tissue anatomic landmarks initially established by Barnette46 were traced for each film. The landmarks were traced for the untreated and treated samples at both time points and then digitized using Dentofacial Planner software (version 7.0; Dentofacial Planner, Toronto, Ontario, Canada). In this software, 2 reference planes were constructed to create an x-y coordinate grid: a horizontal line was created level with nasion at an angle parallel to the sella-nasion line minus 7 , and a vertical line was created perpendicular to the
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Table I. Landmarks
Fig 1. Reference planes (modified from Barnette46).
parallel line to the sella-nasion line minus 7 passing through sella. These planes are shown in Figure 1. Descriptive data were obtained, and a statistical analysis was performed using the Statistical Package for the Social Sciences (version 18; SPSS, Chicago, Ill). Descriptive statistics and variable analyses were calculated for 14 landmarks. Facial measurements, soft tissue thicknesses, and soft tissue lengths were also analyzed (Table I). The landmarks used for this study are illustrated in Figure 2. Independent t tests were performed with a set significance level of P \0.05 to appraise the changes in position of the 14 landmarks and to ascertain the changes in facial measurements, soft tissue thicknesses, and soft tissue lengths. The percentages of enlargement were considered for both samples. Mellion47 had previously determined that specific films from the extraction group nearly 25 years after treatment had a reduction in magnification. This was due to the use of a different cephalostat and the consequent reduction in the object to film distance. All films from the Bolton study were produced with the Bolton cephalometric technique, in which there was a constant anode to object distance of 5 feet, and the object to film distance, also called the midline to lateral film distance, was kept to a minimum.48 The midline to lateral film value is therefore unique for each patient and also unique to each film. The midline to lateral film distance was recorded for each film traced and then converted to the percentage of enlargement from the Bolton standard technique. Once all enlargement values were identified, a conversion factor was found from the effect of distance from the subject to the film.49 All distances were adjusted to 0% enlargement (ie, life size). Microsoft
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Abbreviation Na Na0 Rhn Rhn0 Prn Int Sbn Sls Ls Li Lmf Pog Pog0 Me Me0 A B U1 L1
Cephalometric point Nasion Soft tissue nasion Rhinion Soft tissue rhinion Pronasale Inferior nasal tip Subnasale Superior labial sulcus Labrale superius Labrale inferius Labiomental fold Pogonion Soft tissue pogonion Menton Soft tissue menton A-point B-point Maxillary incisor tip Mandibular incisor tip
Fig 2. Landmarks shown in Table I used in analysis (modified from Barnette46).
Word and Excel from Microsoft Office (edition 2007; Microsoft, Redmond, Wash) were used for the construction of tables and graphs. Profile images detailing the soft tissue changes for the descriptive statistics of each sample were created using Adobe Illustrator (version CS11; Adobe, San Jose, Calif). RESULTS
The study was designed to determine whether there is a significant difference in the soft tissue facial
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Table II. Comparison of posttreatment differences and 251 years posttreatment differences for the untreated and extraction-treated samples Measurement x Prn y Prn x Int y Int x Sls y Sls x Ls y Ls x Li y Li x Lmf y Lmf x Pog0 y Pog0 x Me0 y Me0 x A-point y A-point x U1 y U1 x L1 y L1 x B-point y B-point x Pog y Pog x Me y Me
Untreated, mean 6 SD (mm) 7.62 6 5.38 1.74 6 5.15 7.31 6 5.50 2.14 6 5.09 5.68 6 5.67 3.61 6 4.92 4.88 6 6.53 5.27 6 5.18 8.45 6 7.17 1.47 6 5.95 9.96 6 7.96 4.69 6 5.90 11.62 6 9.08 6.38 6 6.53 11.62 6 10.16 7.42 6 7.18 7.20 6 5.23 2.53 6 4.62 8.21 6 6.44 1.99 6 4.80 7.79 6 6.30 2.53 6 5.00 8.68 6 7.82 3.16 6 5.76 10.38 6 8.77 5.19 6 6.72 10.48 6 9.25 5.62 6 6.88
Extraction-treated, mean 6 SD (mm) 4.32 6 5.28 1.13 6 4.45 4.42 6 5.64 0.08 6 4.00 3.39 6 7.39 1.19 6 3.86 3.80 6 8.28 1.86 6 3.76 3.38 6 9.32 1.92 6 4.06 8.57 6 10.03 0.03 6 4.78 11.13 6 11.45 1.83 6 5.44 12.67 6 12.20 1.05 6 4.41 4.50 6 6.54 0.22 6 3.42 6.86 6 9.21 0.49 6 3.21 6.23 6 8.93 0.69 6 3.54 8.26 6 10.27 0.12 6 4.34 10.05 6 11.77 0.65 6 4.34 10.49 6 12.24 1.09 6 4.42
t 3.16 3.06 2.64 3.36 1.33 2.83 0.75 3.90 1.25 3.45 0.78 4.48 0.24 3.89 0.45 5.58 2.30 2.95 0.89 1.92 1.02 3.87 0.23 3.32 0.16 4.18 0.00 4.09
Significance (2-tailed) 0.002* 0.003* 0.010* 0.001* 0.187 0.006* 0.468 0.000* 0.214 0.001* 0.439 0.000* 0.813 0.000* 0.657 0.000* 0.024* 0.004* 0.396 0.058 0.311 0.000* 0.820 0.001* 0.872 0.000* 1.000 0.000*
x, horizontal; y, vertical. *P #0.05.
profiles of adults who did not undergo orthodontic treatment compared with the profiles of patients who had extraction orthodontic treatment as teens. This study is relevant and important, particularly in our society that believes in nonextraction at all costs. We hope that it will give our specialty some useful and important information about the long-term impact of extraction treatment on the facial profile. Independent t test comparisons between the untreated and extraction-treated samples at posttreatment and recall are shown in Table II. The differences were significant for horizontal and vertical pronasale, horizontal and vertical inferior nasal tip, vertical superior labial sulcus, vertical labrale superius, vertical labrale inferius, vertical labiomental fold, vertical soft tissue pogonion, vertical soft tissue menton, horizontal and vertical A-point, vertical mandibular incisor tip, vertical B-point, vertical pogonion, and vertical menton. For all landmarks that had significance, the changes were greater in the untreated sample, but the direction of change was more horizontal than vertical in the treated sample.
Independent t tests were performed to ascertain the significant differences between posttreatment and recall for the untreated and the extraction-treated samples. Results for facial measurements, soft tissue thicknesses, and soft tissue lengths are given in Tables III-V. For the facial measurements (Table III), the changes in hard tissue facial angle, nasolabial angle, mentolabial fold, and upper and lower anterior facial height were significantly different. The hard tissue facial convexity angle changed more in the extraction-treated sample and became less convex. The nasolabial angle and the mentolabial angle changed more in the untreated sample and became less convex. The upper and lower anterior facial heights changed more in the untreated sample and became larger. Soft tissue thickness differences (Table IV) between posttreatment and recall were compared. Rhinion and B-point in the untreated sample changed more and became thicker than in the extraction-treated sample. Soft tissue length (Table V) changed significantly over the time interval studied. Upper and lower lips and nose lengths changed significantly more in
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Table III. Comparison of posttreatment and 251 years posttreatment facial measurement differences Facial measurement Na0 -Prn-Pog0 ( ) Na–A-point–Pog ( ) (reference to 180 ) Int-Sbn-Ls ( ) Li-Lmf-Pog0 ( ) (reference to 180 ) Na0 -Sbn (mm) Sbn-Me0 (mm)
Untreated, mean 6 SD (mm) 1.81 6 5.03 1.60 6 11.37 4.44 6 8.54 22.89 6 26.26 3.22 6 3.31 3.69 6 4.87
Extraction-treated, mean 6 SD (mm) 1.49 6 4.10 5.39 6 7.52 0.96 6 7.29 0.15 6 14.68 0.73 6 2.32 1.21 6 3.48
Significance (2-tailed) 0.72 0.046* 0.026* 0.000* 0.000* 0.000*
t 0.36 2.03 2.25 5.6 4.52 6
*P #0.05.
IV. Comparison of posttreatment and 251 years posttreatment soft tissue thickness differences
Table
Untreated, Soft tissue mean 6 thickness (mm) SD (mm) Rhn-Rhn0 0.37 6 0.86 A-point–Sls 0.76 6 3.39 B-point–Lmf 1.43 6 1.59 Pog-Pog0 1.48 6 1.97
Extractiontreated, mean 6 Significance SD (mm) t (2-tailed) 0.04 6 0.95 2.31 0.023* 0.1 6 2.68 1.1 0.274 0.31 6 1.16 4.18 0.000* 0.93 6 1.94 1.44 0.154
Table V. Comparison of posttreatment and 251 years
posttreatment soft tissue length differences
Soft tissue length (mm) Sbn-Ls Lmf-Li Na0 -Prn
Untreated, mean 6 SD (mm) 3.91 6 3.22 1.44 6 2.11 4.85 6 3.91
Extractiontreated, mean 6 SD (mm) 2.23 6 1.70 0.24 6 2.17 1.76 6 2.78
t 3.44 2.87 4.72
Significance (2-tailed) 0.001* 0.005* 0.000*
*P #0.05.
*P #0.05.
the untreated sample than in the extraction-treated sample. Figure 3 is a visual representation of the changes from posttreatment to recall for the untreated and extraction-treated samples. DISCUSSION
Craniofacial growth and changes in the adult craniofacial complex began to be studied in the 1970s. Israel50,51 ascertained that the craniofacial complex increased in size well into adulthood. He postulated that this increase was a consequence of remodeling, not sutural expansion. Susanne52,53 studied the cephalograms of 44 subjects who were measured twice between the ages of 25 and 60 years. He found increases in the length and the breadth of the head. He found increases in nasion to stomion height and in facial height. He concluded that growth continued into the fourth and even into the sixth decade of life. State-of-the-art studies of the cranial and facial changes during adulthood were done by Behrents.11 His findings, previously described, were consistent with what was found in the untreated sample. Although the age range of the Bolton-Brush subjects studied by Behrents, who were also used as the untreated sample in this study, was greater than the age range of the treated subjects, the results of the study are the same
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as they would have been had the untreated age range been closer to that of the treated sample. This statement can be made because Behrents found that the skeletal and soft tissue changes during the fifth and sixth decades of life were small. The untreated sample showed the greatest changes for hard and soft tissue pogonion and menton. Although the change was large in the horizontal direction, it also had a significant vertical component. A moderate amount of change in the horizontal direction was seen in the untreated sample for labiomental fold, Point B, labrale inferius, mandibular incisor tip, maxillary incisor tip, Point A, pronasale, and inferior nasal tip. A moderate amount of vertical change in the untreated sample was seen in labiomental fold, Point B, mandibular incisor tip, maxillary incisor tip, Point A, and inferior nasal tip. All landmarks with a moderate horizontal change also showed a moderate vertical change, except for maxillary incisor tip, labrale inferius, and pronasale. Superior labial sulcus and labrale superius showed small amounts of horizontal change, but the superior labial sulcus had a moderate vertical change, whereas labrale superius had a large vertical component change. Labrale inferius, maxillary incisor tip, and pronasale all showed small vertical changes. Landmark changes for the untreated and extraction samples had both vertical and horizontal components. A moderate horizontal change was seen in labiomental fold and B-point. These landmarks also showed a small
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Fig 3. Changes from posttreatment to recall for the untreated sample (left) and extraction-treated sample (right).
Fig 4. Ricketts' E-plane at posttreatment for the untreated (black line) and extraction-treated (red line) samples.
Fig 5. Ricketts' E-plane at 251 years posttreatment for the untreated (black line) and extraction-treated (red line) samples.
vertical component. Small amounts of horizontal and vertical changes were seen for labrale inferius, mandibular incisor tip, maxillary incisor tip, A-point, pronasale, inferior nasal tip, superior labial sulcus, and labrale superius. Interestingly, the vertical components for B-point, labrale inferius, mandibular incisor tip,
pronasale, and inferior nasal tip changed in the upward direction. This study confirmed that mandibular prognathism in an untreated sample increases with age,10,12 as does mandibular prognathism in an extraction-treated sample.27,30,31 MacGilpin et al54 reached a similar conclusion.
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profile. The conclusions drawn from this study are the following. 1. There is no substantive esthetic difference between untreated and extraction-treated samples at a long-term recall evaluation. 2. There are different directional changes for the soft tissue profiles of subjects who were untreated and those treated with extractions. 3. The soft tissue changes for the untreated sample were greatest for the lips and chin. Change was in a downward and forward direction. 4. The soft tissue changes for the extraction-treated sample were generally greatest for the lips and chin. Change was primarily in a forward direction. 5. Extractions do not adversely impact the esthetics of a soft tissue facial profile over time. REFERENCES
Fig 6. Lip and chin changes for the untreated (solid lines) and extraction-treated (dotted lines) samples.
To further evaluate the esthetics of the soft tissue profiles for both the untreated and extraction-treated samples, the E-plane of Ricketts8 was used. Figures 4 and 5 show the E-plane for the posttreatment untreated and extraction-treated samples and for the recalled untreated and extraction-treated samples, respectively. According to Ricketts, the ideal adult lower lip should be located 4 mm behind the E-plane 6 3 mm. The untreated sample at posttreatment had a lower lip to E plane measurement of 2 mm; the treated sample measured 4 mm. At the recall, the untreated lower lip was 5 mm and the treated was 7 mm; both were within Ricketts' acceptable range. Therefore, both samples at posttreatment and recall were considered to be esthetically acceptable. Figure 6 shows changes for the lips and the chin when nasal changes are disregarded. This figure demonstrates that although the lips and chin create different line angles at posttreatment, at recall the samples create similar line angles located close together. This fact further confirms that treatment with extractions does not “flatten” the soft tissue facial profile when the extraction profile is compared with the untreated profile. CONCLUSIONS
This study was designed to provide some evidence about whether the extraction of premolars has significant long-term effects on the esthetics of the soft tissue
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1. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 1970; 40:284-318. 2. Asbell M. Norman W. Kingsley (1928-1913). Am J Orthod Dentofacial Orthop 1999;115:101. 3. Asbell MB. A brief history of orthodontics. Am J Orthod Dentofacial Orthop 1990;98:206-13. 4. Angle EH. The treatment of malocclusion of the teeth. 7th ed. Philadelphia: S. S. White; 1907. 5. Tweed CH. Indications for extraction of teeth in orthodontic procedures. Am J Orthod Surg 1944;30:405-28. 6. Steiner C. Cephalometrics in clinical practice. Am J Orthod 1959; 29:8-29. 7. Casko JS, Shepherd WB. Dental and skeletal variation within the range of normal. Angle Orthod 1984;54:5-17. 8. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod 1968;54:272-89. 9. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod 1984;85: 279-93. 10. Burstone C. Integumental contour and extension patterns. Angle Orthod 1959;9:93-104. 11. Behrents RG. Growth in the aging craniofacial skeleton. Monograph 17. Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1985. 12. Subtelny J. A longitudinal study of soft tissue facial structures and their profile characteristics, defined in relation to underling skeletal structures. Am J Orthod 1959;45:481-507. 13. Forsberg CM. Facial morphology and ageing: a longitudinal cephalometric investigation of young adults. Eur J Orthod 1979;1: 15-23. 14. Sarn€as KV, Solow B. Early adult changes in the skeletal and softtissue profile. Eur J Orthod 1980;2:1-12. 15. Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-tissue profile changes: a study of three analyses. Am J Orthod 1985;88: 209-23. 16. Nanda RS, Meng H, Kapila S, Goorhuis J. Growth changes in the soft tissue facial profile. Angle Orthod 1990;60:177-90. 17. Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop 1994;105: 464-76.
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37. Roos N. Soft-tissue profile changes in Class II treatment. Am J Orthod 1977;72:165-75. 38. Garner LD. Soft-tissue changes concurrent with orthodontic tooth movement. Am J Orthod 1974;66:367-77. 39. Lo FD, Hunter WS. Changes in nasolabial angle related to maxillary incisor retraction. Am J Orthod 1982;82:384-91. 40. Perkins RA, Staley RN. Change in lip vermilion height during orthodontic treatment. Am J Orthod Dentofacial Orthop 1993;103: 147-54. 41. Kasai K. Soft tissue adaptability to hard tissues in facial profiles. Am J Orthod Dentofacial Orthop 1998;113:674-84. 42. Hanson RA. Incisor retraction and lip response with various extraction patterns in Caucasian females [thesis]. St Louis: Saint Louis University; 2003. Accessed April 1, 2014. 43. Luppanapornlarp S, Johnston LE Jr. The effects of premolarextraction: a long-term comparison of outcomes in “clear-cut” extraction and nonextraction Class II patients. Angle Orthod 1993;63:257-72. 44. Cloward DJ. Facial profile changes with extraction of four first premolars in Caucasian, Class I, minimally-crowded, adolescent patients [thesis]. St Louis: Saint Louis University; 2013. Accessed April 1, 2014. 45. Zierhut EC, Joondeph DR, Artun J, Little RM. Long term profile changes associated with successfully treated extraction and nonextraction Class II, Division I malocclusions. Angle Orthod 2000; 70:208-19. 46. Barnette KA. A Longitudinal cephalometric study of the soft tissue profile of male and female orthodontically treated Class I and Class II subjects [thesis]. St Louis: Saint Louis University; 2008. Available at: http://www.slu.edu/Documents/Cade/Thesis/Barnette_Thesis. pdf. Accessed November 4, 2013. 47. Mellion N. A longitudinal, multivariate analysis of orthodontic relapse [thesis]. St Louis: Saint Louis University; 2011. Available at: http://www.slu.edu/Documents/cade/thesis/Mellion_Thesis_ 2010.pdf. Accessed November 4, 2013. 48. Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton standards of dentofacial development growth. St Louis: C. V. Mosby; 1975. 49. Thurow R. Atlas of orthodontic principles. St Louis: C. V. Mosby; 1970. 50. Israel H. Age factor and the pattern of change in craniofacial structures. Am J Phys Anthropol 1973;39:111-28. 51. Israel H. The dichotomous pattern of craniofacial expansion during aging. Am J Phys Anthropol 1977;47:47-52. 52. Susanne C. Individual age changes of the morphological characteristics. J Hum Evol 1977;6:181-9. 53. Susanne C. Aging, continuous changes of adulthood. In: Johnston FE, Roche AF, Susanne C, editors. Human physical growth and maturation. New York: Plenum Press; 1978. p. 111-24. 54. MacGilpin DH, Araujo EA, Behrents RG, Rowan KB. Spatial changes in the relationship of the mandible and maxilla with different extraction patterns and techniques. Angle Orthod 2011;81:584-91.
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