Treatment and posttreatment changes in patients with

Class II, Division 1 malocclusion after extraction and

nonextraction treatment
Samir E. Bishara, BDS, DDS, D. Ortho., MS, a David M. Cummins, DDS, MS, b and
Abbas R. Zaher, BChD, MS, PhD c
Iowa City, Iowa, Bellingham, Wash., and Alexandria, Egypt

T h e purpose of this study was to evaluate the treatment and posttreatment changes in the facial and
dental parameters in two groups of patients with Class II, Division 1 malocclusions. In one group
(n = 46), the patients were treated with a nonextraction approach, whereas in the second group
(n = 45), the treatment included the extraction of four first premolars. The treatment groups were
compared with matched untreated normals (n - 35) from the Iowa Growth Study. Lateral cephalograms
and dental casts were evaluated at three stages: pretreatment, posttreatment, and approximately 2
years after treatment. Student's t tests were used to compare the extraction and nonextraction
groups. Significance was predetermined at p _< 0.05. The cephalometric findings indicate that before
treatment, the subjects treated with four first premolar extractions had more protrusive upper and
lower lips and a larger tooth size-arch length discrepancy. After treatment the upper and lower lips
were more retrusive in the extraction groups, and more protrusive in the nonextraction groups. The
extraction groups tended to have straighter faces and slightly more upright maxillary and mandibular
incisors, whereas the nonextraction groups had the opposite tendencies. The average soft tissue and
skeletal measurements for both groups were close to, but on opposite sides of, the corresponding
averages derived from the Iowa normative standards. The findings from the dental arch measurements
indicate that after treatment both the extraction and nonextraction groups experienced an increase in
tooth size-arch length discrepancy and a reduction in arch length. In general, extractions did not
significantly alter the direction of the overall posttreatment trends. Furthermore, the trends in the
posttreatment changes were similar in male and female patients, as well as in the maxillary and
mandibular arches. The current findings suggest that the extraction/nonextraction decision, if based
on sound diagnostic criteria, does not have a systematic detrimental effect on the facial profile. But
clinicians should be aware of the trends introduced by the two treatment modalities to avoid
accentuating undesirable profile characteristics. (Am J Orthod Dentofac Orthop 1997;111:18-27.)

Although this lord of weak remembrance, this, earliest conception. At the turn of the century, there
Who shall be of as little memory were few sources from which practitioners could
When he is earth'd hath here almost persuaded. learn the principles of "regulating" teeth. Followers
William Shakespeare of Angle's "new school" believed that, if the teeth
The Tempest, act 2, scene 1 were in harmony, the face would be as well. 1,2 They
believed that with their appliances they could make
EXTRACTION VERSUS NONEXTRACTION: the bone grow, obviating the need for extractions.
THE UNENDING DEBATE! On the other hand, the "rational school" of Case
The study of beauty and harmony of the face has and his followers believed that malocclusions were
been central to the practice of orthodontics from its inherited and are the result of mixing the various
face types and races. They contended that bone
Support for the research from the American Association of Orthodontists
Foundation. could not be encouraged to grow beyond its inherent
aProfessor of Orthodontics, University of Iowa. potential, and therefore extractions were necessary
bprivate practice, Bellingham, Wash. to treat some malocclusions.3 The debate was also a
CAssistant Professor, Faculty of Dentistry, Alexandria University, Alexan-
dria, Egypt. clash of egos, often deteriorating into personal
Reprint requests to: Dr. Samir Bishara, Department of Orthodontics, attacks.4
University of Iowa College of Dentistry, 220 Dental Science S, Iowa City, Unfortunately, the debate is still ongoing, and
IA 52242-1001.
Copyright © 1997 by the American Association of Orthodontists. some clinicians still suggest, without providing much
0889-5406/97/$5.00 + 0 8/1/65034 evidence, that four first premolar extractions will

18
American Journal of Orthodontics and Dentofacial Orthopedics Bishara, Cummins, and Zaher 19
Volume 111, No. 1

compromise posttreatment esthetics by "dishing in" maintained, 17-19 but the increases were relatively
the profile,5-9 whereas others have an unfounded more stable in the maxilla than in the mandible. 21
belief that a nonextraction approach places the teeth Other investigators found that lower incisor crowd-
in an unstable position. 1° ing recurred after treatment, 14'17'19'2~'22accompanied
with a decrease in arch length. 18,~9
LONG-TERM CHANGES AFTER TREATMENT When evaluating the long-term stability of cases
Changes do occur after orthodontic treatment, that were treated orthodontically with a nonextrac-
regardless of the techniques used. These changes tion approach, Sadowsky et al. 24 observed that the
may be desirable and called "settling of the occlu- longer the retention period, the greater the stability
sion" or undesirable and labeled "relapse. ''11,12 Sa- of incisor alignment.
dowsky and Sakols, 13 in their study on long-term
stability of orthodontic treatment, evaluated the CHANGES THAT OCCUR WITHOUT TREATMENT
changes in the dental relationship a minimum of 12 Harris and Behrents 27 evaluated the long-term
years after the completion of orthodontic treatment. stability of the dental relationship on 61 orthodon-
They found that 72% of the patients showed dental tically untreated cases. They observed that, when
relationships that were outside the ideal range. the molars were malrelated at the initial observa-
However, in most cases, patients showed an im- tion, they did not self-correct at the end of the
provement in their occlusion. They also observed an observation period, rather the relationship became
increase in the overbite, crowding of the lower progressively worse.
incisors, and to a lesser degree an increase in the Bishara et al. 28 evaluated cephalometric and
overj et. dental arch changes in 35 untreated normal subjects
Little, Wallen, and Riede114 evaluated 65 cases from early adolescence to early adulthood. They
treated with four first premolar extractions and observed that the tooth size-arch length discrepancy
followed these cases for 10 years in retention. Their (TSALD) tended to increase with time in both male
results indicated that arch length and width gener- and female subjects. These changes were not signif-
ally decreased, whereas crowding increased. In ad- icantly related to any one dental or facial variable,
dition, stability of mandibular anterior alignment and they concluded that the cause for the decrease
was only observed in less than 30% of the cases. in arch length is multifactorial. In a more recent
They concluded that variables such as the severity of study, Bishara et al.29 further evaluated the normal
initial crowding, age, gender, Angle classification, changes that occur between 25 and 45 years of age.
and length of retention were not useful parameters They estimated that the total increase in TSALD
in predicting the stability of mandibular incisor between early adolescence (13 years) and mid adult-
alignment. hood (45 years) to be on the average -2.7 mm in the
Shields et al. ~5 also examined cases treated with mandibular arch and -1.9 mm in the maxillary arch
four first premolar extractions assessed at least 10 in male subjects. The corresponding values for fe-
years after retention. They found that the long-term male subjects were -3.5 and -2.0 mm.
response of the lower incisor alignment was unpre- In summary, the orthodontic treatment plan is
dictable and not related to various cephalometric determined by the characteristics of the malocclu-
parameters, such as maxillary and mandibular inci- sion, as well as by the training and biases of the
sor inclination, horizontal and vertical facial growth clinician who is treating the malocclusion. Often,
direction, and the steepness of the mandibular plane orthodontists have different treatment philosophies,
angle. treatment mechanics, and treatment plans but are
still able to obtain comparable acceptable results at
LONG-TERM CHANGES AFTER the end of treatment. But are these diverse treat-
NONEXTRACTION TREATMENT ment approaches equally stable and do they provide
Changes after expansion of the dental arches equally acceptable profiles? Furthermore, do extrac-
received considerable interest from several investi- tions prevent or influence the direction of the
gators. 1626 In general, it has been observed that the posttreatment changes?
increase in the mandibular intercanine width during The purpose of this study is to evaluate the
treatment tends to relapse after treatment. 16-19Even treatment and posttreatment cephalometric and
in cases where the canines were moved distally in dental arch changes in two groups of patients with
the arch, their width still tended to decrease after Class II, Division 1 malocclusions. In one group, the
treatment. 2° Intermolar expansion was also not well patients were treated with a nonextraction approach
20 Bishara, Cummins, and Zaher American Journal of Orthodontics and Dentofacial Orthopedics
January 1997

The identification of the landmarks was based on the

classic definitions described in the publications. 3°-35
All landmarks were identified by one investigator and
checked for accuracy of location by a second investigator.
The landmarks were digitized twice on separate occasions
S " N
by two investigators. Allowable intrainvestigator and in-
terinvestigator measurement discrepancies were predeter-
mined at 0.5 mm and 0.5°.
Twenty-six anteroposterior and vertical skeletal, den-
tal, and soft tissue linear and angular measurements were
derived and included; SNA, SNB, SWPog, SNPog, ANB,
NAPog, N-Ans', N~Me, N-Ans'/N-Me, Ar'-Go, S-Go,
Ar'-Go/S-Go, S-Go/N-Me, FH: MP, SN: MP, U1 : L1, U1 :
SN, Uf:APog, LI:MP, LI:FH, LI:NB, Pog:NB, G1-
SnPog', Ls-Pog' :NB, Ls:Pr-Pog', and Li:Pr-Pog'.

,Pog'
Dental Cast Analysis
Arch widths, lengths, and TSALDs were measured
from the maxillary and mandibular dental casts. :°,2~ A
Fig. 1. Landmarks used. total of 38 parameters were evaluated.

Statistics
Descriptive statistics for the absolute measurements
and in the second group, they were treated with the and incremental changes were calculated for each param-
extraction of four first premolars. eter, at each of the three stages of treatment. The Analysis
of Variance and Student t tests were used to compare the
changes in the extraction and nonextraction groups for
MATERIALS AND METHODS both male and female subjects separately. The level of
Subjects significance was set at p <--0.05.
A total of 91 patients were treated for their Class II,
Division 1 malocclusions. Forty-five patients (21 males
RESULTS
and 24 females) were treated with four first premolar
extractions and 46 patients (20 males and 26 females) Because of the large number of parameters
were treated without extractions. All patients were compared in this study, only the significant differ-
white. ences will be presented.
Case selection was based on the following criteria:
(1) All cases were originally diagnosed as having a Class Gender Differences
II, Division 1 malocclusion. (2) All cases received
Comparisons of male and female subjects indi-
comprehensive orthodontic treatment with an edgewise
cated the presence of significant differences in their
appliance and the appropriate type of extraoral appli-
ance (headgear). (3) None of the cases had congenital absolute pretreatment and posttreatment dimen-
anomalies, significant facial asymmetries, or congeni- sions. Furthermore, the treatment changes were also
tally missing teeth. (4) Records were taken before and not identical in the male and female subjects. As a
after orthodontic treatment. In addition, a third set was result, the findings on both genders will be pre-
obtained approximately 2 years after the completion sented separately.
of orthodontic treatment. (5) At the end of treatment,
all cases were considered to be well treated clinically, Age Comparisons
i.e., displayed a Class I canine and molar relationship, The age distributions of the subjects in each
an overbite between 10% and 25%, and well-aligned treatment and gender subgroup are detailed in
and interdigitated arches. These criteria were adopted Table I.
to insure that the posttreatment changes were not
Student t test comparisons of the male and
caused by poor treatment results or lack of patient
female extraction and nonextraction groups indi-
cooperation.
cated that before treatment, the two groups were
Cephalometric Landmarks and Measurements well matched according to age. However, the length
All cephalograms were obtained on the same cepha- of treatment in the extraction groups were signifi-
lometric unit with the lips at rest. Eighteen hard tissue and cantly longer than the nonextraction groups, by 6 to
six soft tissue landmarks were identified on each cephalo- 8 months in both male (p = 0.016) and female
gram (Fig. 1). (p = 0.048) subjects.
American Journal of Orthodontics and Dentofacial Orthopedics Bishara, Cummins, and Zaher 21
Volume 111, No. 1

Table I. A v e r a g e a g e s o f t h e s u b j e c t s in y e a r s at t h e d i f f e r e n t s t a g e s o f t r e a t m e n t a n d t h e a v e r a g e t r e a t m e n t a n d r e t e n t i o n i n t e r v a l s

Extraction Nonextraction

Subjects Mean 1 SD Mean I SD p-value

Male n = 21 n = 20
Pretreatment 11,5 1.6 12.1 1.5 0.1848
Posttreatment 14.6 1.4 14.5 1.2 0.7470
Retention 16.8 1.6 16.5 1.3 0.4973
Treatment interval* 3.1 0.9 2.3 1.2 0.0160
Retention interval 2.3 0.5 2.1 0.2 0.5356
Female n = 23 n = 27
Pretreatment 11.6 1.6 10.9 1.5 0.1222
Posttreatment 14.4 1.6 13.2 1.2 0.0003
Retention 16.8 1.7 15.3 1.2 0.0004
Treatment interval* 2.9 0.9 2.3 1.1 0.0480
Retention interval 2.4 0.5 2.i 0.3 0.0350

*Treatment interval includes a lag of 3 to 4 months between the time the initial records were taken and the actual treatment was initiated.

Table IIA. R e s u l t s o f S t u d e n t ' s t test i n d i c a t i n g significant d i f f e r e n c e s in t h e i n c r e m e n t a l c h a n g e s b e t w e e n e x t r a c t i o n a n d

nonextraction male subjects

Extraction Nonextraction

Treatment interval £ SD .f~ SD

Pretreatment/posttreatment
SkP: SNA (o) -2.5 1.5 -1.1 1.7 **
NAPog (°) -6.7 3.3 -3.2 3.4 **
N-Ans' (ram) 4.7 2.7 3.0 2.2 *
N-Ans'/N-Me (%) 0.3 1.l -0.4 1.2 *
Pog:NB (ram) 2.8 1.4 0.8 1.3 **
DP: U I : L 1 (o) 4.3 12.8 -4.6 10.1 *
UI:A-Pog (ram) -4.6 2.4 -1.5 2.0 **
LI:N-B (ram) -0.4 1.7 1.8 1.6 **
L I : F H (°) -2.2 7.6 -8.1 72 *
STP: GllnPg (o) -2.2 3.2 0.5 3.0 **
Pr-Pog:NB (°) -6.8 3.4 -1.8 2.6 **
ls:Pr-Pog' -3.9 2.0 1.3 1.4 **
li:Pr-Pog;por -3.9 2.0 0.8 2.0 **
Posttreatment/retention
SkP: MP:FH (°) -0.8 2.6 -2.7 3.0 *
STP: ls-E (mm) -0.7 1.9 1.2 1.3 **
li-E (ram) -0.7 1.5 0,8 2.2 **
Pretreatment/retention
SkP" SNA (°) -2.4 1.7 -0.8 1.5 **
SWPog (°) 0.5 2.5 - 1.4 3.3 *
NAPog (°) -8.4 4.0 -4.4 3.6 **
N-Ans' (ram) 6.5 2.3 4.7 2.6 *
Pog:NB (ram) 3.6 1.5 1.5 1.2 **
DP: UI:L1 (°) 6.7 11.1 -0.7 9.0 *
UI:A-Pog (mm) -4,4 2.6 -1.7 2.1 **
LI:N-B (ram) -0.6 1.8 1.2 1.5 **
LI:MP (°) 0.1 6,0 4.2 6.5 *
STP: G l S n P o g (°) -2.6 3.7 0.3 4.5 *
Pr-Pog:NB (°) -7.3 4.0 -3.0 3.0 **
ls:Pr-Pog f -4.6 2.4 2.4 1.6 **
li:Pr-Pog' -4.9 2.3 1.6 1.8 **

£, Mean; SD, standard deviation; S, statistically significant; SkP, skeletal parameters; DP, dental parameters; STP, soft tissue parameters.
*p < 0.05; **p ~ 0.01.

The findings on the dentofacial structures will be treatment changes in the dentofacial complex
presented in three parts, to address the following that occur after either extraction or nonex-
questions: traction?
1. What are the differences between the post- 2. What are the pretreatment differences be-
22 Bishara, C u m m i n s , and Z a h e r American Journal of Orthodontics and Dent@cial Orthopedics
January 1997

T a b l e liB. R e s u l t s o f S t u d e n t ' s t t e s t i n d i c a t i n g s i g n i f i c a n t d i f f e r e n c e s in t h e i n c r e m e n t a l c h a n g e s b e t w e e n e x t r a c t i o n a n d
n o n e x t r a c t i o n female s u b j e c t s

Extraction Nonextraction

Treatment interval Y~ SD SD

Pretreatment/posttreatment
SkP" SNA (°) -2.0 1.6 -0.9 1.3 *
NAPog (°) -5.1 3.3 -3.0 3.1 *
Pog:NB (mm) 1.8 1.2 0.8 0.8 **
DP: UI:L1 (°) 12.3 13.6 -1.1 10.5 **
UI:A-Pog (ram) -4.6 1.9 1.9 2.5 **
UI:SN (o) -9.8 8.2 -3,2 9.2 **
LI:N-B (ram) -1.4 2.1 1,1 1,6 **
L I : F H (°) 1.4 8.1 -5.5 6.9 **
LI:MP (°) -2.3 8.4 3.8 5.2 **
STP: GISnPog' (°) -2.8 2.1 -1.1 2.3 **
Pr-P:NB (°) -6.2 2.5 -2.7 2.8 **
ls:Pr-Pog" -3.6 1.4 1.2 1.8 **
li:Pr-Pog' -3.0 1.6 0.2 1.7 **
Posnreatment/retention
SkP: N-AJ~s' (ram) 0.1 1.3 0.9 1.2 *
A r ' - G o (ram) 1.3 2.7 2.8 2.3 *
S-Go (ram) 1.5 2.2 3.4 2.9 **
MP:FH (°) -0.2 2.9 -1.9 3.1 *
DP: LI:M-B (mm) 0.0 0.6 -0.4 0.8 *
L I : F H (o) 0.5 3.4 3.8 3.7 **
STP: ls:Pr-Pog' -0.6 1.2 0.9 1.1 **
li-Pr-Pog' -0.8 1.4 1.2 1,1 **
Pretreatment/retention
SkP: SNA (o) -1.6 1.4 -0.4 1.7 **
SNB (°) -0.2 1.2 0.9 1.9 *
A r ' - G o (mm) 4.6 3.0 6.4 2.9 *
S-Go (mm) 6.6 3.3 8.6 3.1 *
N-Me (mm) 7.1 3.4 9.5 4.4 *
Pog:NB (mrn) 2.4 1,4 1.1 0.8 **
DP: UI:L1 (°) 13,0 12,1 2.3 9.2 **
UI:A-Pog (ram) -4,3 2.2 -1.8 2.2 **
UI:SN (o) -9.4 8.0 -3.0 8.6 **
LI:N-B (mm) -1.3 2.0 0.7 1.4 **
LI:MP (°) -2.5 7.2 1.8 4.5 *
STP: Pr-P:NB (°) -7.2 3.2 -4.1 3.0 **
ls-E (mm) -4.1 1.7 2.1 2.1 **
li-E (turn) -3.9 1.8 1.4 1.8 **

tween the Class II, Division I subjects treated was a greater decrease in the facial skeletal convexity
with and without extractions? In other words, (NAPog) and an increase in chin prominence (Pog:
is there a quantifiable basis for the extraction- N-B) in the extraction groups, as compared with the
nonextraction decision? And, nonextraction groups in both male and female sub-
3. After treatment, what are the differences in jects. These findings suggest that during treatment
the dentofacial relationships between the ex- planning, if such outcomes are desirable, an extraction
traction, nonextraction, and untreated normal approach might enhance these changes.
groups? How do the treatment groups differ There were no significant differences in the
from each other and from matched normal changes in the inclination of the mandibular plane
subjects? between the various treatment groups.
Soft Tissue Relationships: Similar to the skeletal
COMPARISONS OF THE TREATMENT CHANGES changes, the soft tissue facial convexity (G1 Sn Pog')
BETWEEN GROUPS decreased more in the extraction groups during the
Cephalometric Comparisons (Tables IIA and liB) treatment period. Also, the upper (Ls:Pr-Pog')
Skeletal Relationships: During treatment, there and lower lip (Li:Pr-Pog') prominence decreased
American Journal of Orthodontics and Dent@cial Orthopedics Bishara, C u m m i n s , a n d Z a h e r 23
Volume 111, No. 1

Table III. D e s c r i p t i v e a n d c o m p a r a t i v e statistics o f the changes in the d e n t a l a r c h w i d t h s a n d T S A L D s d u r i n g ( T 2 - T 1 ) a n d a f t e r (T3-

T 2 ) t r e a t m e n t f o r m a l e a n d f e m a l e p a t i e n t s w i t h C l a s s II, D i v i s i o n 1 m a l o c c l u s i o n s w h o w e r e t r e a t e d w i t h a n d w i t h o u t t h e e x t r a c t i o n
o f f o u r first p r e m o l a r s

Males Females

Nonextraction Extraction Nonextraction Extraction

Parameters 2 ] SD £ SD 2 ] SD £ SD p
t
Maxillary arch width
Interincisor
T2-T1 0.8 1,5 2.3 2.4 S* 1.5 2.2 2.4 2.3 NS
T3-T2 0.2 0.9 -0.6 1.1 S* -0.2 0,5 -0.2 0.8 NS
T3-T1 1.0 1.3 1.6 2.4 NS 1.3 2,1 2.2 2.2 NS
Intercanine
T2-T1 0,5 1.8 3.2 2.4 S** 2.0 2.3 3.1 3.5 NS
T3-T2 0.6 0,8 0,0 2,2 NS 0.0 0.8 - 0.3 1,3 NS
T3-TI 1.1 1.9 3.3 2.0 S** 2.0 2.5 2.8 2.8 NS
Interpremolar
T2-T1 2.1 1.6 0.8 2.4 NS 3.3 2.8 1.5 3.0 S*
T3-T2 0.4 0.9 -0.3 3.0 NS -0.2 1.1 -0.7 1.7 NS
T3-T1 2.5 1.5 0.5 4.3 NS 3.1 2.5 0.7 2.8 S **
Intermolar
T2-T1 1.2 1.4 -0,9 2.6 S** 1.8 2.6 0,0 0.6 S*
T3-T2 0.5 0.9 0.5 2.3 NS 0.2 1.0 0,6 2.1 NS
T3-T1 1.7 1.5 - 0.3 2.9 S* 2. i 2. l - 0.6 2.5 S**
Maxillary TSALD
T2-T1 0.1 2.4 4.6 5.3 S*'* 0.3 2.8 4.1 4.9 S**
T3-T2 -0.5 0.6 - 1.1 1.1 NS - 1.0 1.2 -0.9 1.4 NS
T3-T1 -0.4 2.3 3.5 4.9 S** -0.7 2.7 3.2 4.8 S**
Mandibular arch width
Interincisor
T2-T1 1.0 1.3 1.7 2.7 NS 0.2 0. 1.9 1.2 S**
T3-T2 -0.2 0.5 -0.8 2.4 NS -0.1 0.4 0.4 0.5 S*
T3-T1 0.8 1.3 0.9 1.7 NS 0.1 0.6 1.4 1.0 S**
Intercanine
T2-T1 0.3 1.6 1.1 4.1 NS 0.5 1.7 1.6 2.0 S*
T3-T2 -0.1 0.8 -0.7 3.0 NS -0.2 0.7 -0.7 1.1 NS
T3-T1 0.2 1.4 -0.5 2.3 NS 0.3 1.6 1.0 1.9 NS
Intersecond premolar
T2-T1 0.1 1.8 -0.6 3,7 NS 0.6 2.6 -0.2 2.9 NS
T3-T2 0.7 0.9 -0.5 3,0 NS 0.2 1.2 -0.6 1,6 S*
T3-T1 0.7 1.9 1.1 4,2 NS 0.8 2.1 -0.8 2,7 S*
Intermolar
T2-T1 0.7 1.6 - 1.9 2.9 S** 0.5 2.3 - 1.0 3.2 S*
T3-T2 0.7 1.2 0.1 2.8 NS 0.2 1.2 -0.7 1.6 S*
T3-T1 1.4 1.6 -1.7 2.4 S** 0.7 2.0 -1.7 2.6 S**
MandibuIar TSALD
T2-T1 0.0 3,0 4.2 3.9 S** -1.2 2.2 3.8 4.1 S**
T3-T2 - 1.4 0.8 - 1.2 1.3 NS - 1.2 0.9 - 1.3 1.2 NS
T3-T1 -l.4 2.9 3.0 3.6 S** -2.4 2.3 2.5 4.0 S**

2, Mean; SD, standard deviation; T1, initial; T2, end of treatment; T3, retention; P0 resuIts of analysis of variance; S , statistically significant at p - 0.05; S**,
statistically significant a t p -< 0.01; NS, not significant.

relative to the nose and chin in the extraction the extraction groups during the period of active
groups. treatment as a result of the greater retraction of the
During the retention period, lip prominence upper and lower incisors. Such changes help explain
decreased further among the extraction groups and the greater amount of lip retraction seen among the
increased among the nonextraction groups accentu- extraction groups.
ating earlier trends. During the retention period, there were no
Dental Relationships: The interincisal angle significant differences in the changes in lower incisor
(U1 :L1) became significantly more obtuse among position or angulation between the groups.
24 Bishara, C u m m i n s , a n d Z a h e r American Journal of Orthodontics and Dentofacial Orthopedics
January 1997

T a b l e IVA, R e s u l t s o f S t u d e n t ' s t t e s t i n d i c a t i n g s i g n i f i c a n t differences b e t w e e n t h e a b s o l u t e d i m e n s i o n s o f t h e e x t r a c t i o n a n d

nonextraction male subjects

Extraction Nonextraction

Treatment interval 2 SD 2 SD S

Pretreatment
SkP: N-Me (mm) 123.4 4.4 117.8 7.6 **
A r ' - G o (ram) 47.7 4.2 51.3 4.9 *
S-Go (mm) 80.0 5.1 84.5 4.5 **
DP: LI:MP (°) 92.0 6.3 97.0 6.6 *
STP: ls:Pr-Pog' (mm) 1.0 1.9 - 1.3 1.7 **
li:Pr-Pog' (mm) 1.5 2.4 -1.9 2.7 **
Posttreatment
SkP: A r ' - G o (ram) 51.8 5.5 55.4 5.4 *
NAPog (°) 1.4 4.9 5.8 4.5 **
Pog:NB (mm) 4.9 2.4 2.8 2.3 **
DP: UI:L1 (°) 133.1 9.6 121.7 9.3 **
UI:A-Pog (ram) 2.3 1.2 5,2 2.1 **
LI:N-B (ram) 2.9 1.2 6,1 1.7 **
L I : F H (°) 58.8 6.9 48,9 5.0 **
LI:MP (°) 94.3 8.4 103.1 6.6 **
STP: Pr-P:NB (°) 10.0 4.6 13.9 3.7 **
ls:Pr-Pog' -2.9 1.6 -0.1 1.7 **
Retention
Ski': NAPog (°) -0.2 6.1 4.2 4.5 **
N-Me (ram) 131.2 8.1 135,7 5.9 *
Pog:NB (mm) 5.8 2.5 3.5 2.4 **
DP: UI:L1 (°) 135.5 9.6 125.7 9.1 **
UI:A-Pog (ram) 2.5 1.9 5.0 2.3 **
LI:N-B (ram) 2.7 1.5 5.5 2.2 **
L I : F H (°) 61.4 5.4 53.5 6.8 **
LI:MP (°) 92.6 7.6 101.2 7.1 **
STP: Pr-P:NB (°) 9.5 5.3 12.6 4.3 *
ls:Pr-Pog' -3.6 2.3 1.1 2.2 **
li:Pr-Pog' -3.4 2.2 -0.3 2.8 **

2, Mean; SD, standard deviation; S, statistically significant; SkP, skeletal parameters; DP, dental parameters; STP, soft tissue parameters.
*p -< 0.05; **p -< 0.01.

Dental Arch Comparisons (Table III) Pog') and lower lips (Li:Pr-Pog') were more
During treatment, the incisor and canine widths protrusive, relative to the esthetic plane, among the
significantly increased in the extraction groups. This extraction groups. On the other hand, there were no
is the result of the alignment of the crowded ante- differences between the two groups in any of the other
rior segment. After treatment, there was an increase 22 dentofacial parameters compared. As a result, it
in TSALD in both treatment groups. seems that lip protrusion was an important quantifi-
The posttreatment changes in the extraction and able profile characteristic on which the extraction
nonextraction groups showed similar overall trends decision was made, at least in the current sample.
in the interincisor and intercanine widths, but dif- Comparisons of TSALD between the extraction
ferent trends in intermolar widths. and nonextraction groups (Table V) indicated the
presence of significant differences between the two
PRETREATMENT AND POSTRETENTION groups. The extraction groups had, on the average, a
COMPARISONS BETWEEN THE GROUPS deficiency of - 2 . 4 and - 2 . 3 mm for male and
(TABLES IVA AND IVB) female subjects, respectively, in the maxillary arch
These comparisons should provide the clinician and - 1 . 8 and - 2 . 1 mm in the mandibular arch. The
with some insight as to the criteria on which the nonextraction groups had an excess space of 1.0 and
extraction decision was based. The significant cepha- 1.2 mm for male and female subjects, respectively, in
lometric differences between the extraction and non- the maxillary arch and 0.8 and 2.1 mm in the
extraction groups indicated that the upper (Ls:Pr- mandibular arch (Table V).
American Journal of Orthodontics and Dentofacial 0tthopedics Bishara, Cummins, and Zaher 25
Volume 111, No, 1

Table IVB. R e s u l t s o f S t u d e n t ' s t test i n d i c a t i n g s i g n i f i c a n t differences b e t w e e n t h e a b s o l u t e d i m e n s i o n s o f t h e e x t r a c t i o n a n d

nonextraction female subjects

Extraction Nonextraction

Treatment interval SD 2 SD S

Pretreatment
STP: li:E (ram) 1.1 2.9 -1.0 2.2 **
Posttreatment
SkP: N-Ans' (ram) 53.7 3.0 55.5 3.5 *
DP: UI:L1 (°) ' 134.6 10.1 i25.5 8.9 **
UI:A-Pog (ram) 2.8 1.9 5.0 1.7 **
UI:SN (°) 98.1 7,6 102.6 5,8 *
LI:N-B (ram) 3,4 2.2 5.1 1.7 **
L I : F H (°) 58.8 8.2 54.5 6.6 *
LI:MP (o) 94.1 7.4 98.8 7.2 *
STP: ls:Pr-Pog' -3.3 2.2 1,2 1.9 **
Retention
SkP: N-Ans' (ram) 53.8 3.2 56.5 3.4 **
N-Me (ram) 123.2 6.6 127.4 7.9 *
S-Go (ram) 85.3 7.0 88.9 5.2 *
DP: UI:L1 (°) 135.3 9.4 128.9 6.9 **
UI:A-Pog (ram) 3.1 1.9 5.1 1.7 **
UI:SN (°) 98.4 5.7 102.7 6.1 *
LI:N-B (ram) 3.4 2.0 4.7 1.4 **
STP: ls:Pr-Pog' -3.8 2.1 2.1 2.3 **
li:Pr-Pog' -2.8 3.1 0.3 2.4 **

POSTTREATMENT COMPARISONS BETWEEN THE esthetics and comparable stability of the treatment
GROUPS results. The current findings might help explain the
(-fABLES IVA AND IVB) advantages and disadvantages, as well as the limita-
Posttreatrnent comparisons are useful in deter- tions of both treatment approaches.
mining the presence of any differences between the
extraction and nonextraction groups after comple- Profile Changes
tion of the orthodontic and orthopedic treatment The pertinent clinical question is whether the
changes. It should be emphasized that such direct treatment changes were desirable or detrimental to
comparisons do not determine, per se, whether one the facial profile. Such a determination can be
group "looks" better than the other. attempted by comparing the treatment changes with
The skeletal and soft tissue angles of facial those observed in matched normative subjects de-
convexity were significantly straighter in the male rived from the Iowa Growth Study36 (Table VI). The
extraction group as compared with the nonextrac- extraction groups tend to have straighter faces and
tion group. Female subjects had similar trends, but slightly more upright maxillary and mandibular in-
the differences were not as significant. The lips were cisors, whereas the nonextraction groups have the
more retrusive in the extraction groups when com- opposite tendencies. The averages in both groups,
pared with the nonextraction groups in both male however, remain close to the Iowa normative stan-
and female subjects. dards.
Essentially, the differences between the extrac-
tion and nonextraction groups observed in the post- Dental Arch Changes
treatment comparisons were also present at the end The current findings indicate that an important
of the retention period. clinical variable that influences the extraction deci-
sion is the presence of a crowded dentition. In
DISCUSSION addition, there are other parameters that may also
For almost a century, the use of extractions to influence the extraction decision but are more sub-
treat malocclusions has been hotly debated in or- jective and include the inclination of the incisors,
thodontic circles. 1-26 Both sides of the extraction the treatment philosophy of the clinician, the bio-
debate have claimed similar improvements in facial mechanical principles practiced, the growth poten-
26 Bishara, Cummins, and Zaher American Journal of Orthodontics and Dentofacial Orthopedics
January 1997

Table V. Descriptive and comparative statistics on the Table VI. Means of posttreatment measurements for selected
differences in TSALDs between the extraction and parameters obtained from the extraction, nonextraction, and
nonextraction groups matched Iowa Normative data
Extraction Nonextraction Males Females

2 [ SD 2 SD P Iowa Iowa
Variables Ext Normals Non ext Ext Normals ]Non ex,
Maxillary arch
Males -2.4 5.7 1.0 3.4 0.0347 SkP: N A P o g (°) 1.4 6.4 5.5 4.1 6.0 4,5
Females -2.3 5.7 1.2 3.3 0.0138 DP: U I : S N (°) 99.8 101.6 102.1 98.0 102.1 102.6
L I : M P (°) 94.3 103.1 97.2 94.1 95.4 98.8
Mandibular arch
STP: G1SnPog (°) 164.4 167.5 166.2 166.9 169.0 167.8
Males -1.8 3.6 0.8 3.3 0.0291
Females -2.1 4.6 2.1 2.3 0.0005 NB:Pr-Pog' 10.0 12.8 13.9 10.3 11.3 11.4
Ls:Pr-Pog' ( m m ) 2.9 2.1 0.1 3.3 3.5 1.2
2, Mean; SD, standard deviation; P, probability. Li:Pr-Pog' (ram) 2.4 1.2 1.1 1.9 1.4 0.9

Ext, Extraction group; Nonext, nonextraction group; SkP, skeletal p a r a m -

eters; DP, dental parameters; STP, soft tissue p a r a m e t e r s .
tial of the patient, and the severity o f the anteropos-
terior and vertical dentofacial discrepancies.
The success of orthodontic treatment is also
to avoid accentuating any undesirable esthetic charac-
judged by the stability o f the occlusal results
teristics.
achieved. 1°,13,3739 Yet, there is a general consensus
that teeth have a tendency to m o v e in the direction
REFERENCES
o f the original malocclusion even after the success-
1. Angle E. Malocclusion of the teeth. 7th ed. Philadelphia: SS White, 1907.
ful completion of orthodontic treatment. 1°13,3s-43 2. Dewel BF. The Case-Dewey-Cryer extraction debate: a commentary. Am J Orthod
Such changes should be considered as either related 1964;50:862-5.
3. Case CS. The question of extraction in orthodontia. Am J Orthod 1964;50:660-91.
to "physiologic rebound ''~2'13 or are part of the 4. The extraction debate of 1911, by Case, Dewey and Cryer. Discussion of Case: the
normal developmental changes. 12'2s'29 Regardless, question of extraction in orthodontia. Am J Orthod 1964;50:751-68.
5. Stoner CC. An interview: AAFO's man of the year 1984, Dr. John W, Witzig. Funct
orthodontists should clearly explain to their patients Orthod 1984;1(4):9-15.
these p h e n o m e n a and also take them into consider- 6. Bowbeer GRN. The sixth key to facial beauty and TMJ health. Funct Orthod
1987;4:4-20.
ation during treatment planning, regardless of 7. Bowbeer GRN. The five keys to facial beauty and TMJ health. Funct Orthod
whether the ease will be treated with an extraction 1985;2:12-29.
8. Bowbeer GRN. Saving the face and the TMJ. Funct Orthod 1985;2:32-44.
or a nonextraction approach. 9. Bowbeer GRN. Saving the face and the TMJ--part 2. Funct Ortbod 1986;3:9-24.
10. 3~veed CH. Indications for the extraction of teeth in orthodontic procedures. Am
CONCLUSIONS J Orthod Oral Surg 1944;30:405-28.
11. Hellman M. Fundamental principles and expedient compromises in orthodontic
From the current findings, it can be concluded: procedures, Am J Orthod Oral Surg 1944;30:429-36.
12. Horowitz SL, Hixon EH. Physiologic recovery following orthodontic treatment.
1. Pretreatment, lip protrusion, and TSALDs are Am J Orthod 1969;55:1-4.
important characteristics that influence the extrac- 13. Sadowski C, Sakols EI. Long-term assessment of orthodontic relapse. Am J Orthod
1982;82:456-63.
tion decision. 14. Little RM, Wallem TR, Riedel RA. Stability and relapse of mandibular anterior
2. After treatment: (a) The skeletal and soft tissue alignment--first premolar extraction cases treated by traditional edgewise orth-
facial profiles were straighter in the extraction odontics. Am J Orthod 1981;80:349-65.
15. Shields TE, Little RM, Chapko MK. Stability and relapse of mandibular anterior
groups; (b) the upper and lower lips were more alignment--a cephalometric appraisal of first-premolar-extraction cases treated by
retrusive in the extraction groups and more protru- traditional edgewise orthodontics. Am J Orthod 1985;87:27-38.
16. Gardner SD, Chaconas SJ. Posttreatment and postretention changes following
sive in the nonextraction groups; and (c) the upper orthodontic therapy. Angle Orthod 1976;46:151-61.
and lower incisors were retracted and uprighted 17. Johnson KC. Cases six years postretention. Angle Orthod 1977;47:210-21.
more among the extraction groups. 18. Herberger RJ. Stability of mandibular intercuspid width after long periods of
retention. Angle Orthod 1981;51:78-83.
3. In retention, the differences between the groups 19. Little RM, Riedel RA, Stein A. Mandibular arch length increase during the mixed
were preserved. dentition: postretention evaluation of stability and relapse. Am J Orthod Dentofac
4. The posttreatment trends in the cephalometric and Orthop 1990;97:393-404.
20. Sondhi A, Cleall JF, BeGole EA. Dimensional changes in the dental arches of
dental arch changes were similar in male and orthodontically treated cases. Am J Orthod 1980;77:60-73.
female subjects, as well as in the maxilla and the 21. Lombardi AIR. Mandibular incisors crowding in completed cases. Am J Orthod
1972;61:374-83.
mandible. 22. Dacre JT. The long-term effects of one lower incisor extraction. Eur J Orthod
1985;7:136-44.
The current findings suggest that the extraction/ 23. Artun J, Krogstad O, Little RM. Stability of mandibular incisors following excessive
nonextraction decision, if based on sound diagnostic proclination: a study in adults with surgically treated mandibular prognathism.
criteria, does not have a systematic detrimental effect Angle Orthod 1990;60:99-106.
24. Sadowsky C, Schneider BH, BeGolle EA, Tahir E. Long-term stability after
on the facial profile. But clinicians should be aware of orthodontic treatment: nonextraction with prolonged retention. Am J Orthod
the trends introduced by the two treatment modalities Dentofac Orthop 1994;106:243-9.
American Journal of Orthodontics and DentofaciaI Orthopedics Bishara, Cummins, and Zaher 97
Volume 111, No. l

25. Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic therapy: posttreat- 34. Bishara SE. Maxillary growth and development: method of analysis. In: Hughlett
ment dental and skeletal stability. Am J Orthod Dentofac Orthop 1987;92:32I-8. M. The Bratislava project: some results of cleft palate surgery. Iowa City:
26. Walter DC. Changes in the form and dimensions of dental arches resulting from University of Iowa, 1978.
orthodontic treatment. Angle Orthod 1953;23:3-18. 35. Meredith HW, Chadha JM. A roentgenographie study of change in head height
27. Harris EF, Behrents RG. The intrinsic stability of Class I molar relationship: a during childhood and adolescence. Hum Biol 1962;34:299-319.
longitudinal study of untreated cases. Am J Orthod Dentofac Orthop 1988;94:63-7. 36. Bishara SE, Peterson L, Bishara EC. Changes in facial dimensions and relation-
28. Bishara SE, Jacobsen JR, Treder JE, Stasi MJ. Changes in maxillary and ships between the ages of 5 and 25 years. Am J Orthod 1984;85:238-52.
mandibular tooth size-arch length relationship from early adolescence to early 37. Tweed CH. Clinical orthodontics. Vol. 1. St Louis: CV Mosby, 1966:6-82.
adulthood. Am J Orthod Dentofac Orthop 1989;95:46-59. 38. Boese LR, Johnson KC. Cases six years postretention. Angle Orthod 1948;47:210-
29. Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am 21.
J Orthod Dentofac Orthop 1994;106:175-86. 39. Riedel R. Retention. In: Graber TM, Swain BF, eds. Current orthodontics
30. Riolo ML, Moyers RE, McNamara JA, Hunter WS. An atlas of craniofaeial concepts and techniques. Philadelphia: WB Sauuders, 1975:1095-137.
growth: cephalometric standards from the university school growth study. Ann 40. Thurrow RC. Edgewise orthodontics. 2nd ed. St Louis: CV Mosby, 1966:258-74.
Arbor: University of Michigan, 1974. 41. Graber TM. Postmortems in posttreatment adjustment. Am J Orthod 1966;52:331-
3l. Krogman W, Sass0uni V. A syllabus in roentgenographic cephalometry. Philadel- 52.
phia: Philadelphia Center for Research in Child Growth, 1957. 42. ginger J. Posttreatment changes: a reality. Am J Orthod 1975;67:277-89.
32. Sahmann JA. Practice of orthodontics. Philadelphia: JB Lippincott, 1966. 43. Hellman M. Orthodontic results many years after treatment. Am J Orthod Oral
33. Enlow DH. Handbook of facial growth. Philadelphia: WB Sannders, 1975. Surg 1940;26:843-53.