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 sam-
ple. 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 Angle's concepts solely on esthetic grounds. He docu-
4 BC by the Greeks and were studied by the mented the fact that a normal complete dentition occlu-
Egyptians, Romans, and Italians.1 Many ideas sion does not always predispose the patient to ideal
that surround the correction of the irregularities of teeth facial balance. Tweed recognized that facial balance
were first published in Britain by Kingsley in 1880, but and harmony could not be achieved because many
the author did not address the relationship between patients who were treated without extractions had
esthetics and orthodontics.2 In 1900, Angle formally protrusive lips and faces. He contended that these
established orthodontics as a dental specialty and in- patients had profiles that were not esthetically pleasing
sisted that patients whose full complement of teeth because the teeth were too far forward.
was maintained would have superior occlusions.3 He Over the years, cephalometric “norms” have been
was one of the first to define a relationship between or- defined by the specialty.6-10 The effect of growth on
thodontics and facial esthetics. Angle4 strongly believed the soft tissue profile began to be addressed by
that once a superior occlusion was achieved, excellent investigators who detailed changes due to growth
facial esthetics would be the result. Tweed5 challenged alone.11-22 In 1985, Behrents11 documented long-term
soft tissue changes in an untreated sample. He studied
a
Private practice, Yorba Linda, Calif. subjects from the Bolton-Brush growth series; many
b
Pete Sotiropoulos professor of orthodontics and clinic director, Orthodontic
Graduate Program, Saint Louis University, St Louis, Mo. were in their 60s and 70s when recalled. The following
c
Private practice, Cookeville, Tenn. changes in the facial profiles of these untreated patients
d
Professor, Department of Orthodontics, Center for Advanced Dental Education, were found. (1) There was an increase in nasal projec-
Saint Louis University, St Louis, Mo.
e
Professor, Department of Orthodontics, Center for Advanced Dental Education, tion. The nasal tip moved inferiorly. (2) Both lips became
Saint Louis University, St Louis, Mo. less prominent and tended to move inferiorly. The upper
All authors have completed and submitted the ICMJE Form for Disclosure of Po- lip tended to move down and back, and this led to less
tential Conflicts of Interest, and none were reported.
Address correspondence to: James L. Vaden, 308 E First St, Cookeville, exposure of the maxillary teeth. (3) The nasolabial angle
TN 38501; e-mail, jlvaden@[Link]. became more acute. Essentially, Behrents found and
Submitted, July 2012; revised and accepted, January 2015. described a clockwise rotation of the nasolabial complex.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists. Recently, there has been debate on both sides of the
[Link] issue of where teeth should be left during adolescent
596
Rathod et al 597

treatment to compensate for these documented changes an attempt to match the 10- to 17-year posttreatment
that occur in the aging face. The extraction- films of the extraction sample to the sample that had
nonextraction debate is flourishing again. In 1994, Prof- received no treatment. The sole inclusion criterion
fit23 looked at changes in the extraction rate over the (aside from high-quality cephalometric films with
previous 40-year period. He estimated that the extrac- discernible soft tissue profiles) was that no subject
tion rates were 30% in 1953, 76% in 1968, and 28% had received orthodontic treatment. Films were chosen
in 1993. Sarver et al24 contended that teeth should be consecutively until no more persons met the inclusion
left in a forward position because of the changes that criterion. The subjects in the Bolton-Brush sample
will occur to the face. Specifically, they stated, “First, had Angle Class I, Class II, or Class III malocclusions.
in designing treatment for the adolescent, the orthodon- Each subject was included in the study because his or
tist usually is the first professional to make decisions on her facial profile at 10 to 17 years of age matched
how a patient will look for the rest of his or her life. For the posttreatment profiles of the patients in the treated
instance, anterior teeth that were retracted in adoles- sample.
cence to correct a protrusion, even though they looked A sample of 47 orthodontic patients was selected
good initially, may appear overretracted 20 years later. from a collection of files of patients who were recalled
The experience in the 1950s and 1960s of high extrac- approximately 25 years after their premolar extraction
tion rates and profile flattening has resulted in many un- treatment was completed. Of these patients, 31 had
esthetic facial outcomes. For these patients, there is loss Angle Class II malocclusions, 15 had Angle Class I
of lip thickness with aging which makes the lack of lip malocclusions, and 1 had an Angle Class III malocclu-
support from the teeth even more obvious.” sion. All treated patients had extractions before treat-
As a result of this expressed and valid concern, ment to ameliorate crowding, reduce facial protrusion,
numerous published studies have documented changes facilitate Class II dentition correction, or accomplish a
in the soft tissue profile after both extraction and nonex- combination of any of these goals. The films were cho-
traction orthodontic treatments.25-42 Luppanapornlarp sen consecutively until there were no more patients who
and Johnston43 studied samples of “clear-cut” extrac- met the criteria. To meet the inclusion criteria, the pa-
tion and nonextraction patients. They found that the pa- tient needed to have high-quality cephalometric films
tients treated without extractions in fact had the flattest taken after treatment and again nearly 25 years later.
faces in their sample. Cloward44 went a step farther and As with the untreated sample films, all had to show
studied the impact of 4 first premolar extractions on the good soft tissue definitions and contain all landmarks
facial profiles of patients with minimal crowding. As ex- necessary for analysis. Films were chosen consecutively
pected, Cloward found profile changes in those subjects. until there were no more patients who met the criteria.
Zierhut et al45 determined that when the faces of a Class All patients in the treated sample had 4 teeth extracted
II Division 1 extraction treatment sample were compared before orthodontic treatment. The premolar extractions
with the faces of a Class II Division 1 nonextraction sam- were in the following patterns: 4 first premolars, 4 sec-
ple, they are similar. Even more interesting was that after ond premolars, maxillary first premolars and mandibular
14 years, the faces in the sample of Zierhut et al, second premolars, or 3 premolars and a badly decayed
although they had flattened somewhat, remained first molar. Most important is that all were treated in a
similar. The changes were, therefore, maturational and private practice by the same clinician (J.L.V.), who had
had nothing to do with the extractions or the lack similar treatment objectives for all patients who were
thereof. included in the sample.
This study was initiated to find some answers to these
seemingly continual questions. It was completed in an Statistical analysis
attempt to help solve the controversy of what impact, Hard and soft tissue anatomic landmarks initially es-
if any, extractions have on the aging face. tablished by Barnette46 were traced for each film. The
landmarks were traced for the untreated and treated
MATERIAL AND METHODS samples at both time points and then digitized using
A sample of 57 untreated subjects was selected from Dentofacial Planner software (version 7.0; Dentofacial
the Bolton-Brush study at Case Western Reserve Uni- Planner, Toronto, Ontario, Canada). In this software, 2
versity in Cleveland, Ohio. The search on the Bolton reference planes were constructed to create an x-y coor-
database focused on subjects who had cephalometric dinate grid: a horizontal line was created level with na-
films taken between 10 and 17 years of age and again sion at an angle parallel to the sella-nasion line minus
after 30 years of age. These age groups were selected in 7
, and a vertical line was created perpendicular to the

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598 Rathod et al

Table I. Landmarks
Abbreviation Cephalometric point
Na Nasion
Na0 Soft tissue nasion
Rhn Rhinion
Rhn0 Soft tissue rhinion
Prn Pronasale
Int Inferior nasal tip
Sbn Subnasale
Sls Superior labial sulcus
Ls Labrale superius
Li Labrale inferius
Lmf Labiomental fold
Pog Pogonion
Pog0 Soft tissue pogonion
Me Menton
Me0 Soft tissue menton
A A-point
B B-point
Fig 1. Reference planes (modified from Barnette46). U1 Maxillary incisor tip
L1 Mandibular incisor tip

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 anal-
ysis was performed using the Statistical Package for the
Social Sciences (version 18; SPSS, Chicago, Ill). Descrip-
tive statistics and variable analyses were calculated for
14 landmarks. Facial measurements, soft tissue thick-
nesses, and soft tissue lengths were also analyzed
(Table I). The landmarks used for this study are illus-
trated 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 thick-
nesses, 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 Fig 2. Landmarks shown in Table I used in analysis
(modified from Barnette46).
films from the Bolton study were produced with the Bol-
ton cephalometric technique, in which there was a con-
stant anode to object distance of 5 feet, and the object to
film distance, also called the midline to lateral film dis- Word and Excel from Microsoft Office (edition 2007; Mi-
tance, was kept to a minimum.48 The midline to lateral crosoft, Redmond, Wash) were used for the construction
film value is therefore unique for each patient and also of tables and graphs. Profile images detailing the soft
unique to each film. The midline to lateral film distance tissue changes for the descriptive statistics of each sam-
was recorded for each film traced and then converted to ple were created using Adobe Illustrator (version CS11;
the percentage of enlargement from the Bolton standard Adobe, San Jose, Calif).
technique. Once all enlargement values were identified,
a conversion factor was found from the effect of dis- RESULTS
tance from the subject to the film.49 All distances were The study was designed to determine whether
adjusted to 0% enlargement (ie, life size). Microsoft there is a significant difference in the soft tissue facial

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Rathod et al 599

Table II. Comparison of posttreatment differences and 251 years posttreatment differences for the untreated and
extraction-treated samples
Measurement Untreated, mean 6 SD (mm) Extraction-treated, mean 6 SD (mm) t Significance (2-tailed)
x Prn 7.62 6 5.38 4.32 6 5.28 3.16 0.002*
y Prn 1.74 6 5.15 1.13 6 4.45 3.06 0.003*
x Int 7.31 6 5.50 4.42 6 5.64 2.64 0.010*
y Int 2.14 6 5.09 0.08 6 4.00 3.36 0.001*
x Sls 5.68 6 5.67 3.39 6 7.39 1.33 0.187
y Sls 3.61 6 4.92 1.19 6 3.86 2.83 0.006*
x Ls 4.88 6 6.53 3.80 6 8.28 0.75 0.468
y Ls 5.27 6 5.18 1.86 6 3.76 3.90 0.000*
x Li 8.45 6 7.17 3.38 6 9.32 1.25 0.214
y Li 1.47 6 5.95 1.92 6 4.06 3.45 0.001*
x Lmf 9.96 6 7.96 8.57 6 10.03 0.78 0.439
y Lmf 4.69 6 5.90 0.03 6 4.78 4.48 0.000*
x Pog0 11.62 6 9.08 11.13 6 11.45 0.24 0.813
y Pog0 6.38 6 6.53 1.83 6 5.44 3.89 0.000*
x Me0 11.62 6 10.16 12.67 6 12.20 0.45 0.657
y Me0 7.42 6 7.18 1.05 6 4.41 5.58 0.000*
x A-point 7.20 6 5.23 4.50 6 6.54 2.30 0.024*
y A-point 2.53 6 4.62 0.22 6 3.42 2.95 0.004*
x U1 8.21 6 6.44 6.86 6 9.21 0.89 0.396
y U1 1.99 6 4.80 0.49 6 3.21 1.92 0.058
x L1 7.79 6 6.30 6.23 6 8.93 1.02 0.311
y L1 2.53 6 5.00 0.69 6 3.54 3.87 0.000*
x B-point 8.68 6 7.82 8.26 6 10.27 0.23 0.820
y B-point 3.16 6 5.76 0.12 6 4.34 3.32 0.001*
x Pog 10.38 6 8.77 10.05 6 11.77 0.16 0.872
y Pog 5.19 6 6.72 0.65 6 4.34 4.18 0.000*
x Me 10.48 6 9.25 10.49 6 12.24 0.00 1.000
y Me 5.62 6 6.88 1.09 6 4.42 4.09 0.000*
x, horizontal; y, vertical.
*P #0.05.

profiles of adults who did not undergo orthodontic Independent t tests were performed to ascertain the
treatment compared with the profiles of patients significant differences between posttreatment and
who had extraction orthodontic treatment as teens. recall for the untreated and the extraction-treated
This study is relevant and important, particularly in samples. Results for facial measurements, soft tissue
our society that believes in nonextraction at all costs. thicknesses, and soft tissue lengths are given in
We hope that it will give our specialty some useful and Tables III-V. For the facial measurements (Table III),
important information about the long-term impact of the changes in hard tissue facial angle, nasolabial
extraction treatment on the facial profile. Independent angle, mentolabial fold, and upper and lower anterior
t test comparisons between the untreated and extrac- facial height were significantly different. The hard
tion-treated samples at posttreatment and recall are tissue facial convexity angle changed more in the
shown in Table II. The differences were significant extraction-treated sample and became less convex.
for horizontal and vertical pronasale, horizontal and The nasolabial angle and the mentolabial angle
vertical inferior nasal tip, vertical superior labial changed more in the untreated sample and became
sulcus, vertical labrale superius, vertical labrale infe- less convex. The upper and lower anterior facial heights
rius, vertical labiomental fold, vertical soft tissue changed more in the untreated sample and became
pogonion, vertical soft tissue menton, horizontal larger. Soft tissue thickness differences (Table IV) be-
and vertical A-point, vertical mandibular incisor tip, tween posttreatment and recall were compared. Rhin-
vertical B-point, vertical pogonion, and vertical men- ion and B-point in the untreated sample changed
ton. For all landmarks that had significance, the more and became thicker than in the extraction-treated
changes were greater in the untreated sample, but sample. Soft tissue length (Table V) changed signifi-
the direction of change was more horizontal than cantly over the time interval studied. Upper and lower
vertical in the treated sample. lips and nose lengths changed significantly more in

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600 Rathod et al

Table III. Comparison of posttreatment and 251 years posttreatment facial measurement differences
Untreated, Extraction-treated, Significance
Facial measurement mean 6 SD (mm) mean 6 SD (mm) t (2-tailed)
Na0 -Prn-Pog0 (
) 1.81 6 5.03 1.49 6 4.10 0.36 0.72
Na–A-point–Pog (
) (reference to 180
) 1.60 6 11.37 5.39 6 7.52 2.03 0.046*
Int-Sbn-Ls (
) 4.44 6 8.54 0.96 6 7.29 2.25 0.026*
Li-Lmf-Pog0 (
) (reference to 180
) 22.89 6 26.26 0.15 6 14.68 5.6 0.000*
Na0 -Sbn (mm) 3.22 6 3.31 0.73 6 2.32 4.52 0.000*
Sbn-Me0 (mm) 3.69 6 4.87 1.21 6 3.48 6 0.000*

*P #0.05.

Table IV. Comparison of posttreatment and Table V. Comparison of posttreatment and 251 years
251 years posttreatment soft tissue thickness differ- posttreatment soft tissue length differences
ences
Extraction-
Extraction- Untreated, treated,
Untreated, treated, Soft tissue mean 6 mean 6 Significance
Soft tissue mean 6 mean 6 Significance length (mm) SD (mm) SD (mm) t (2-tailed)
thickness (mm) SD (mm) SD (mm) t (2-tailed) Sbn-Ls 3.91 6 3.22 2.23 6 1.70 3.44 0.001*
Rhn-Rhn0 0.37 6 0.86 0.04 6 0.95 2.31 0.023* Lmf-Li 1.44 6 2.11 0.24 6 2.17 2.87 0.005*
A-point–Sls 0.76 6 3.39 0.1 6 2.68 1.1 0.274 Na0 -Prn 4.85 6 3.91 1.76 6 2.78 4.72 0.000*
B-point–Lmf 1.43 6 1.59 0.31 6 1.16 4.18 0.000*
Pog-Pog0 1.48 6 1.97 0.93 6 1.94 1.44 0.154 *P #0.05.

*P #0.05.
as they would have been had the untreated age range
been closer to that of the treated sample. This statement
the untreated sample than in the extraction-treated can be made because Behrents found that the skeletal
sample. and soft tissue changes during the fifth and sixth de-
Figure 3 is a visual representation of the changes cades of life were small.
from posttreatment to recall for the untreated and The untreated sample showed the greatest changes
extraction-treated samples. for hard and soft tissue pogonion and menton. Although
the change was large in the horizontal direction, it also
DISCUSSION had a significant vertical component. A moderate
Craniofacial growth and changes in the adult cranio- amount of change in the horizontal direction was seen
facial complex began to be studied in the 1970s. in the untreated sample for labiomental fold, Point B,
Israel50,51 ascertained that the craniofacial complex labrale inferius, mandibular incisor tip, maxillary incisor
increased in size well into adulthood. He postulated tip, Point A, pronasale, and inferior nasal tip. A moderate
that this increase was a consequence of remodeling, amount of vertical change in the untreated sample was
not sutural expansion. Susanne52,53 studied the seen in labiomental fold, Point B, mandibular incisor
cephalograms of 44 subjects who were measured twice tip, maxillary incisor tip, Point A, and inferior nasal tip.
between the ages of 25 and 60 years. He found All landmarks with a moderate horizontal change also
increases in the length and the breadth of the head. He showed a moderate vertical change, except for maxillary
found increases in nasion to stomion height and in incisor tip, labrale inferius, and pronasale. Superior labial
facial height. He concluded that growth continued into sulcus and labrale superius showed small amounts of
the fourth and even into the sixth decade of life. horizontal change, but the superior labial sulcus had a
State-of-the-art studies of the cranial and facial moderate vertical change, whereas labrale superius had
changes during adulthood were done by Behrents.11 a large vertical component change. Labrale inferius,
His findings, previously described, were consistent with maxillary incisor tip, and pronasale all showed small ver-
what was found in the untreated sample. Although the tical changes.
age range of the Bolton-Brush subjects studied by Landmark changes for the untreated and extraction
Behrents, who were also used as the untreated sample samples had both vertical and horizontal components.
in this study, was greater than the age range of the A moderate horizontal change was seen in labiomental
treated subjects, the results of the study are the same fold and B-point. These landmarks also showed a small

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Rathod et al 601

Fig 3. Changes from posttreatment to recall for the untreated sample (left) and extraction-treated sam-
ple (right).

Fig 4. Ricketts' E-plane at posttreatment for the un- Fig 5. Ricketts' E-plane at 251 years posttreatment for
treated (black line) and extraction-treated (red line) sam- the untreated (black line) and extraction-treated (red
ples. line) samples.

vertical component. Small amounts of horizontal and pronasale, and inferior nasal tip changed in the upward
vertical changes were seen for labrale inferius, mandib- direction. This study confirmed that mandibular progna-
ular incisor tip, maxillary incisor tip, A-point, pronasale, thism in an untreated sample increases with age,10,12 as
inferior nasal tip, superior labial sulcus, and labrale does mandibular prognathism in an extraction-treated
superius. Interestingly, the vertical components for sample.27,30,31 MacGilpin et al54 reached a similar
B-point, labrale inferius, mandibular incisor tip, conclusion.

American Journal of Orthodontics and Dentofacial Orthopedics May 2015  Vol 147  Issue 5
602 Rathod et al

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.

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American Journal of Orthodontics and Dentofacial Orthopedics May 2015  Vol 147  Issue 5