ORIGINAL ARTICLE

Long-term profile changes in extraction and

nonextraction patients
Corbett K. Stephens,a Jimmy C. Boley,b Rolf G. Behrents,c Richard G. Alexander,d and Peter H. Buschange
Tyler and Dallas, Tex, and Saint Louis, Mo
Introduction: The purpose of this investigation was to determine the long-term differences in soft tissue
profile changes between extraction and nonextraction patients who had been treated to the same incisor
position and lip line. Methods: Twenty extraction and 20 matched nonextraction patients, with posttreatment
and long-term follow-up (average 15 years) records, were selected from a single private orthodontic practice.
Posttreatment and long-term follow-up profile photos of the patients nose, lip, and chin areas were
evaluated by 105 orthodontists and 225 laypeople, who indicated their preferences and the amount of
change they perceived among the 40 profiles. The patients had similar dental protrusion, soft tissue profile
measurements, and ages at the posttreatment observation. Results: No significant cephalometric differences between the extraction and nonextraction groups were found at long-term follow-up; both groups
showed similar long-term changes. Significant (P .05) differences were found between males and females
at long-term follow-up; male lips became relatively more retrusive, and their profiles became flatter.
Significant (P .05) changes in the profiles were also perceived over time, but there was no relationship
between the amount of change perceived and profile changes measured cephalometrically. There were also
no significant (P .05) differences in preferences between orthodontists and laypeople, between extraction
and nonextraction patients, or between males and females. Conclusions: If extraction and nonextraction
patients are treated to the same incisor position and lip line, the treatment modality does not affect long-term
soft tissue profile changes. Furthermore, the amounts of change perceived by either orthodontists or
laypeople were not related to the amount of change measured cephalometrically. (Am J Orthod Dentofacial
Orthop 2005;128:450-7)

he extraction-nonextraction debate, ongoing for

almost 100 years, has often been based more on
supposition than fact.1,2 Those who favor nonextraction have often presumed that extraction treatment tends to dish in the face; those who favor
extraction, on the other hand, often presume the lips
tend to be blown out by excessive incisor flaring. We
now have good data showing only small posttreatment
differences between extraction and nonextraction patients.3-7 Extraction patients tend to be 2 to 4 mm
flatter, on average, than nonextraction patients at the
end of treatment.
Perhaps even more important than the cephalometric comparisons, we now have a better understanding of

Private practice, Tyler, Tex.

Clinical assistant professor, Baylor College of Dentistry, Dallas, Tex.
Professor, Saint Louis University Center for Advanced Dental Education,
Saint Louis, Mo.
d
Clinical professor, Baylor College of Dentistry, Dallas, Tex.
e
Professor, Baylor College of Dentistry, Dallas, Tex.
Reprint requests to: Dr Peter H. Buschang, Department of Orthodontics, Baylor
College of Dentistry, Texas A & M University System, 3302 Gaston Ave,
Dallas, TX 75246; e-mail, phbuschang@tambcd.edu.
Submitted, March 2004; revised and accepted, April 2004.
0889-5406/$30.00
Copyright 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.04.034
b
c

450

profile preferences after extraction and nonextraction

treatments. Regardless of whether cephalometric studies show differences between extraction and nonextraction patients, an important issue is whether the differences can be perceived. It has been shown that
extraction faces are flatter directly after treatment and
are preferred over nonextraction faces by dentists and
laypeople, with the dentists preferring flatter faces more
than laypersons.6 Bishara and Jakobsen,8 who randomly presented extraction and nonextraction profile
silhouettes of pretreatment and posttreatment patients
to laypeople, demonstrated that the general public does
not prefer the profiles of 1 group over the other.
Information about preferences is important because a
major goal of orthodontic treatment is to attain and
maintain a good esthetic result, which ultimately must
be based on the general publics opinions.
The extraction-nonextraction debate has also been
based on suppositions about what occurs after treatment. Lectures and discussion sections often note
anecdotallythat extractions cause long-term dishing
in of the face, and nonextraction therapy causes excessive lip strain and lip incompetence. There have been
few long-term cephalometric comparisons, suggesting
that posttreatment differences between extraction and

Stephens et al 451

American Journal of Orthodontics and Dentofacial Orthopedics

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Table I.

Average ages of subjects and intervals in years

at posttreatment and long-term follow-up
Extraction

Table II.

Cephalometric measurements, definitions, and

method error

Nonextraction
Measurements

Subjects

Mean

SD

Mean

Male
Posttreatment
Long-term follow-up
Posttreatment to longterm follow-up
Female
Posttreatment
Long-term follow-up
Posttreatment to longterm follow-up

(n 6)
15.6
1.5
30.3
3.4
14.7
2.5

(n 6)
15.1
1.5
30.1
5.3
15.0
4.9

(n 14)
14.8
1.1
28.9
5.0
14.1
4.6

(n 14)
15.1
2.2
30.0
4.4
14.9
2.9

Definition

Method
error

SD
N-Pn-Pg ()
N-Sn-Pg ()
Ls-E-Line (mm)
Li-E-Line (mm)
Ls-S-Line (mm)
Li-S-Line (mm)
H-Line (mm)
U1-SN ()
L1-NB (mm)

Total facial convexity

Facial convexity
Upper lip to Ricketts E-line
Lower lip to Ricketts E-line
Upper lip to Steiners S-line
Lower lip to Steiners S-line
Perpendicular distance from Holdaways
H-line to superior labial sulcus
Maxillary incisor to sella-nasion line
Mandibular incisor to nasion-B-point
line

1.40
1.07
0.34
0.29
0.44
0.29
0.28
1.45
0.44

term, but the changes are not significantly different

between extraction and nonextraction groups.3,6,7
We currently have little or no information about
preferences of long-term follow-up profiles of extraction and nonextraction patients. Over the short term, it
has been shown that there is little or no difference in
how orthodontists and laypeople rate the profiles of
extraction and nonextraction patients.8 However, these
patients were followed for only 2 years, and soft tissue
changes take longer to develop in subjects with reduced
growth potential.9 Moreover, Drobocky and Smith10
discussed how subjective evaluations of desirable and
undesirable profiles often do not coincide with differences measured cephalometrically. Because changes
that are not perceived even though they can be
measuredmust be considered highly questionable,
the purpose of this study was to determine whether
long-term differences in soft tissue profile changes
occur between extraction and nonextraction patients,
and, if so, how they are perceived by orthodontists and
laypeople.
Fig 1. Reference lines and landmarks: S, sella; N,
nasion; UIA, upper incisor root apex; UIE, upper incisor
incisal edge; LIE, lower incisor incisal edge; LIA, lower
incisor root apex; B, B-point; N, soft tissue nasion; Pn,
pronasale; Col, columella; Sn, subnasale; Sls, superior
labial sulcus; Ls, labrale superior; Li, labrale inferior; Pg,
soft tissue pogonion.

nonextraction patients are small and relatively insignificant.3-5,7 Paquette et al3 found that most of the significant differences observed between their borderline
extraction and nonextraction patients at the end of
treatment were also present 10 to 15 years later.
Cephalometric evaluations generally show significant
soft tissue profile changes from posttreatment to long

MATERIAL AND METHODS

Forty white, Class I and Class II patients, all treated

by the same orthodontist, were selected for the study.
Twenty patients were treated with 4-premolar extractions, and 20 were treated with a nonextraction protocol. The groups had similar ages at posttreatment and
long-term follow-up; the average long-term interval
was 15 years (Table I). In addition to age and sex, the
extraction and nonextraction patients were matched
according to 3 measurements taken from the immediate
posttreatment cephalograms. Two measurements of
dental protrusion, U1-SN and L1-NB, were chosen
based on a discriminant analysis11 that showed them to
be among the major determining factors in the extraction-nonextraction decision. Holdaways H-line was

452 Stephens et al

American Journal of Orthodontics and Dentofacial Orthopedics

October 2005

Fig 2. Profile photograph comparison.

chosen because it allows evaluation of lip protrusion

independent of nose length. The extraction group was
selected first, with the 3 measurements in the normal
range. Nonextraction patients were then matched to the
extraction patients.
All posttreatment and long-term follow-up cephalograms were traced and digitized with Dentofacial
Planner software (Dentofacial Software, Toronto, Ontario, Canada). Fifteen landmarks (Fig 1), based on
definitions from Riolo et al12 and Daskalogiannakis,13
were digitized. The horizontal and vertical positions of
the landmarks were described by a rectangular (x and y)
coordinate system. Distances were measured relative to
posttreatment sella and oriented along a reference line
constructed from S-N 7 (Fig 1). For example, the
horizontal change in position of pronasale was measured parallel to the reference line (Pn-h) and the
vertical change perpendicular to the reference line
(Pn-v). Nine additional measurements, as defined by
Hsu14 and Subtelny,15 were computed to evaluate
profiles and profile changes (Table II). Replicate analyses of 15 patients showed no significant systematic
errors; method errors ranged from 0.3 to 1.4 mm.
A survey was developed to quantify the amount of
change perceived and to judge the preferences of the
patients profiles. A pilot study was conducted to
determine the number of patients to include in the
survey instrument and to develop a set of instructions
that could be clearly understood. Two versions of the
survey were prepared, each pertaining to approximately
equal numbers of extraction, nonextraction, male, female, Class I, and Class II subjects. Each survey
presented posttreatment and long-term follow-up profile photos (Fig 2) of the 20 patients. The 2 profiles
were randomly displayed between right and left for

each patient. There were 4 profile comparisons per

page, and each survey consisted of a full set of
instructions. The instruction page consisted of a full
instructions, with examples, and an area to indicate the
sex and age of the evaluator and whether he or she was
an orthodontist.
Three groups of evaluators received 1 of the 2
versions of the survey with instructions to compare the
profiles. The evaluators were 115 laywomen, 110
laymen, and 105 orthodontists. They were asked to
indicate their preferences and the amount of difference
they perceived between the 2 profiles. The sample of
laypeople was collected in doctors waiting areas, at the
dental school, and through family and friends. The
sample of orthodontists was collected at orthodontic
meetings, by mailings based on random lists obtained
from the American Dental Association, and by mailings
to Baylors orthodontic alumni. A 60% reply rate was
obtained from the mailings.
The cephalometric and survey data were analyzed
with SPSS software (Chicago, Ill). The amount of
change perceived between the 2 profiles was measured
on a 106-mm visual analog scale with same as the left
anchor and very different as the right anchor. The
distance from the left anchor was measured and divided
by 106 to compute the percentage of change perceived.
T tests were used to compare the extraction and
nonextraction groups. Changes between the posttreatment and long-term follow-up observations were evaluated with paired t tests. Perceived changes were
evaluated by using a single-sample t test and related to
the cephalometric changes by using Pearson productmoment correlations. A chi-square test was used to
compare proportions of preferences expressed.

Stephens et al 453

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 128, Number 4

Table III. Posttreatment and long-term follow-up cephalometric measurements, changes, and group differences for extraction and nonextraction groups
Extraction
Variable
Posttreatment
N-Pr-Pg ()
N-Sn-Pg ()
LS-E-line (mm)
LI-E-Line (mm)
LS-S-line (mm)
LI-S-line (mm)
H-line (mm)
U1-SN ()
L1-NB (mm)
Long-term follow-up
N-Pr-Pg ()
N-Sn-Pg ()
LS-E-Line (mm)
LI-E-Line (mm)
LS-S-Line (mm)
LI-S-Line (mm)
H-Line (mm)
U1-SN ()
L1-NB (mm)
Long-term changes
N-Pr-Pg ()
N-Sn-Pg ()
LS-E-Line (mm)
LI-E-Line (mm)
LS-S-Line (mm)
LI-S-Line (mm)
H-Line (mm)
U1-SN ()
L1-NB (mm)

Table IV. Posttreatment and long-term follow-up cephalometric measurements, changes, and group differences for males and females

Nonextraction

Males

Mean

SD

Mean

SD

Probability
difference

131.2
163.6
5.9
3.6
2.2
1.2
3.7
105.6
3.9

3.3 132.2
4.9 163.5
1.4 5.4
2.2 4.2
1.1 2.4
2.1 2.2
1.1
3.6
6.2 103.8
1.8
3.4

3.4
4.8
2.1
2.2
1.9
2.1
1.3
6.6
1.8

.33
.95
.37
.42
.73
.15
.88
.38
.42

132.1
167.6
7.3
4.9
3.2
2.1
3.7
105.1
3.9

3.4 132.1
4.9 166.4
2.0 7.0
3.0 5.7
1.4 3.5
2.4 3.4
1.2
3.2
6.6 104.9
2.3
3.1

4.2
5.6
2.7
2.7
2.1
2.2
1.1
7.6
2.0

.99
.47
.63
.36
.49
.10
.19
.93
.24

0.9
4.0*
1.5*
1.3*
1.0*
0.9*
0.1
0.6
0.1

2.8
3.5
1.5
1.5
1.4
1.4
1.1
4.3
1.0

3.4
3.7
2.5
2.2
2.0
1.8
1.0
4.0
1.2

.29
.33
.82
.66
.70
.56
.21
.23
.32

0.2
2.9*
1.6*
1.6*
1.2*
1.2*
0.4
1.1
0.3

Variable
Posttreatment
N-Pr-Pg ()
N-Sn-Pg ()
LS-E-Line (mm)
LI-E-Line (mm)
LS-S-Line (mm)
LI-S-Line (mm)
H-Line (mm)
U1-SN ()
L1-NB (mm)
Long-term follow-up
N-Pr-Pg ()
N-Sn-Pg ()
LS-E-line (mm)
LI-E-line (mm)
LS-S-line (mm)
LI-S-line (mm)
H-line (mm)
U1-SN ()
L1-NB (mm)
Long-term changes
N-Pr-Pg ()
N-Sn-Pg ()
LS-E-line (mm)
LI-E-line (mm)
LS-S-line (mm)
LI-S-line (mm)
H-line (mm)
U1-SN ()
L1-NB (mm)

Females
Mean

SD

Probability
difference

Mean

SD

132.8
164.4
5.8
4.7
2.4
2.4
4.0
107.0
3.0

3.5
4.9
1.6
2.1
1.3
1.9
1.3
5.9
1.4

131.3
163.2
5.5
3.5
2.3
1.4
3.5
103.8
3.9

3.2
4.7
1.9
2.2
1.7
2.2
1.2
6.5
1.9

.18
.48
.69
.13
.85
.19
.23
.15
.17

133.4
169.8
9.0
7.6
4.3
4.4
3.8
109.6
2.3

4.4
4.1
2.0
2.5
1.7
2.2
1.3
5.3
1.6

131.5
165.8
6.4
4.3
2.9
2.1
3.3
103.0
4.0

3.4
5.3
2.1
2.4
1.6
2.2
1.1
6.8
2.2

.14
.02
.01
.01
.02
.01
.16
.01
.02

0.6
5.5*
3.2*
3.0*
1.9*
2.0*
0.1
2.6*
0.7

4.3
3.6
2.1
1.7
1.7
1.4
1.0
3.3
1.4

0.3
2.6*
0.9*
0.8*
0.7*
0.7*
0.2
.80
0.1

2.5
3.3
1.5
1.5
1.6
1.5
1.1
4.2
0.9

.79
.02
.01
.01
.03
.01
.87
.02
.08

*Significant (P .05) changes.

*Significant (P .05) changes.

RESULTS

Males and females were not significantly different

at posttreatment (Table IV). Both groups showed significant (P .05) changes over time. Generally, males
showed a greater number of changes and more pronounced changes over time than females. Male lips
became significantly more retrusive in relation to the
esthetic lines and showed greater increases in facial
convexity. Most soft and hard tissue landmarks moved
forward and down more in males than in females (Table
V; Fig 3).
Orthodontists and laypeople perceived 33.9% to
39.2% of the changes between photographs, indicating
a small-to-moderate change (Table VI). The perceived
changes were all statistically significant (P .01).
Variation in amounts of change perceived was high,
ranging from 7.3% to 14.9%. Slightly less change was
perceived for nonextraction than extraction patients,
males were perceived to change more than females, and

No significant differences were found between the

extraction and nonextraction groups at the posttreatment time interval (Table III). Significant (P .05)
changes occurred between posttreatment and long-term
follow-up for 5 of the 9 measurements. These differences were related mainly to the position of the lips,
which became relatively more retruded in both groups.
There was also a significant (P .05) increase in facial
convexity for both groups. Lip protrusion and total
facial convexity showed no significant changes. The
extraction and nonextraction groups showed similar
changes over time; there were no significant group
differences for the changes or for the long-term follow-up measurements. No significant differences were
found between the extraction and nonextraction groups
for the horizontal and vertical changes of the individual
landmarks.

454 Stephens et al

American Journal of Orthodontics and Dentofacial Orthopedics

October 2005

Table V. Sex differences in horizontal (h) and vertical

(v) changes (mm) in the soft-tissue cephalometric
landmarks
Males

Females

Variable

Mean

SD

Mean

SD

Probability
difference

Pn-h
Pn-v
Col-h
Col-v
Sn-h
Sn-v
Sls-h
Sls-v
Ls-h
Ls-v
Li-h
Li-v
Pg-h
Pg-v
UIE-h
UIE-v
UIA-h
UIA-v
LIE-h
LIE-v
LIA-h
LIA-v
B-h
B-v

6.7*
2.7*
4.9*
3.0*
3.5*
2.3
3.4*
3.5*
4.1*
3.5*
5.0*
2.6*
7.9*
5.6*
4.7*
3.1*
4.2*
4.6*
3.9*
1.6
4.6*
3.8*
5.1*
2.2

4.8
2.9
3.6
3.9
3.0
4.1
2.9
3.5
3.7
2.8
3.2
3.5
4.2
4.8
2.6
3.2
2.9
3.3
2.7
3.2
2.8
4.0
3.1
3.8

3.1*
0.4
2.6*
0.8
1.5*
0.7
1.6*
1.9*
1.8*
1.5*
2.5*
1.6*
4.0*
1.8*
3.3*
1.9*
3.3*
1.9*
2.5*
0.2
2.0*
1.3*
2.7*
0.2

3.3
2.5
3.3
2.3
3.3
2.3
3.0
2.1
3.1
2.9
3.2
3.2
3.9
3.8
2.9
3.1
2.6
2.5
2.8
3.1
3.3
3.5
3.2
3.5

.01
.01
.05
.03
NS
NS
NS
NS
.05
.04
NS
.03
.01
.01
NS
NS
.01
NS
NS
NS
.02
.06
.04
NS

laypeople perceived more changes than orthodontists,

but none of these differences was statistically significant.
A moderately high positive correlation (r 0.89; P
.001) was found between the amounts of change
perceived by orthodontists and laypersons. However,
only 1 of the 18 possible correlations between the
actual cephalometric changes and the perceived
changes was statistically significant. The greater the
increase in total angle of facial convexity (N-Pn-Pg),
the greater the change perceived by orthodontists (r
0.34; P .03).
Orthodontists and laypeople showed no clear pattern of preferences between the posttreatment and
long-term follow-up photographs (Table VII). Approximately 30% preferred the posttreatment photograph;
30%, the long-term follow-up photograph; and 30%
chose neither photograph over the other. On average,
orthodontists tended to prefer the posttreatment photographs over the long-term follow-up photographs for all
groups, and the laypeople tended to prefer the longterm photograph for all groups except the males.
Variation in profile preferences was high, and the
differences between orthodontists and laypeople were

not statistically significant. Orthodontists and laypeople

had clear preferences for individual profiles. For 87.5%
of the patients, chi-square analyses showed significant
(P .05) differences in the proportions of orthodontists and laypeople who preferred either posttreatment
long-term follow-up or neither profile over the other.
But there was no consistency of preferences expressed
across cases. For example, approximately 90% of the
orthodontists preferred the long-term photograph for 1
case, whereas 80% preferred the posttreatment photograph for another. Preferences for individual patients
were similar for orthodontists and laypeople.
DISCUSSION

The results clearly showed that the extraction and

nonextraction patients were comparable at the end of
treatment. Both groups had similar amounts of lip
protrusion in relation to the esthetic lines, similar
amounts of dental protrusion, and similar soft tissue
facial convexities. Zierhut et al7 also reported no
significant differences in hard and soft tissue profiles
between their extraction and nonextraction patients
immediately posttreatment, even though there were
pretreatment differences. Perhaps this dictated different
treatment modalities, leading to similar profiles posttreatment. Paquette et al,3 on the other hand, started
with morphologically similar patients at pretreatment
and showed significant differences between their extraction and nonextraction groups at posttreatment. On
average, the extraction group profiles became flatter
and the lips more retrusive (about 2 mm). Others have
also shown group differences at posttreatment, indicating more lip retrusion and decreased facial convexity
with extractions.3,4,16 Our goal was to select a sample
of extraction and nonextraction subjects who were
similar at posttreatment. By meeting this goal, we could
assume that any profile differences between the 2
groups during the posttreatment period must have been
due to the type of treatment (extraction or nonextraction).
Our extraction and nonextraction groups also
turned out to be no different at the long-term follow-up
15 years later, indicating that the changes were similar
for both groups. No significant differences in posttreatment changes between extraction and nonextraction
groups have also been previously reported.3,7 Bishara et
al4 showed that differences between extraction and
nonextraction groups in lip position relative to the
E-line increased during their posttreatment follow-up,
but this was only 2 to 3 years later.
Although they were not different, both groups
demonstrated significant changes over time. Their
lips became significantly more retruded in relation to

Stephens et al 455

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 128, Number 4

Fig 3. Male and female 1:1 scaled illustrations for growth at individual landmarks.

Table VI.

Treatment and sex differences in changes perceived by orthodontists and laypeople

Extraction

Orthodontists
Laypeople
Combined

Nonextraction

Male

Mean

SD

Mean

SD

Probability
difference

35.8
38.2
36.5

12.8
8.2
9.7

33.9
37.5
36.3

13.5
10.1
10.9

.63
.80
.95

Female

Mean

SD

Mean

SD

36.6
39.2
38.3

10.7
6.9
7.9

34.2
37.3
35.6

14.1
10.0
11.0

.59
.57
.45

*Significant (P .05) differences.

Table VII. Percentage of orthodontists and laypeople who preferred posttreatment photo, long-term follow-up photo,
or neither photo
Orthodontist preference
Posttreatment

Extraction
Nonextraction
Male
Female

Long-term

Laypeople preference
Neither

Posttreatment

Long-term

Neither

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Mean

SD

37.5
38.3
42.3
36.0

19.0
26.5
21.9
23.3

36.0
28.9
29.0
34.0

21.2
25.5
21.3
24.5

26.5
32.8
28.7
30.0

17.4
21.0
15.3
21.0

32.0
32.5
36.9
30.3

13.0
16.9
12.4
15.6

38.6
32.9
29.6
38.3

19.1
19.2
13.3
20.8

29.5
34.6
33.5
31.4

14.7
16.8
13.9
16.7

*Significant (P .05) differences.

the E- and S-lines, and their facial convexity decreased considerably over the long term. Similar
posttreatment changes have been reported for both
extraction and nonextraction patients.3,7,16 Those

changes, as well as ours, follow patterns expected for

untreated subjects15,17 and are due to greater relative
growth in the nose and chin areas.18 This suggests
that the extraction and nonextraction patients in this

456 Stephens et al

study, who were chosen for posttreatment similarity,

grew similarly during the posttreatment follow-up
period.
Males and females showed no significant differences in any of the soft tissue profile measurements at
the end of treatment. Lack of significant sex differences
has been previously reported for treated and untreated
subjects.9,20 Bishara et al5 also reported similarities
between males and females at posttreatment for facial
convexity and the relative position of the upper and
lower lips. Untreated males and females have been
shown to differ: in 1 study, females had more protruded
upper lips,19 but, in another study, they had more
retruded upper lips9 than males. Again, the groups in
our study were selected to be similar.
Males and females demonstrated significant differences in their posttreatment changes. Males showed
significantly more retrusion of the lips in relation to the
E- and S-lines than females. Males also had significantly more growth in the soft tissue nose and chin after
treatment (Fig 3). This agrees with growth differences
between males and females originally reported15,21 and
later substantiated by others.18,22 Because the average
posttreatment age of our sample was approximately 15
years, males might be expected to be only 1 year past
peak adolescent velocity and have greater future growth
potential than females. The greater growth potential of
the male nose and chin after puberty causes their lips to
become significantly more retruded in relation to the
E-line than those of females.
Orthodontists and laypeople perceived that similar amounts of change took place between the posttreatment and long-term follow-up photos. The literature pertaining to perception of profiles by dental
professionals and laypeople is equally divided in
regard to perceptions.6,8,23-26 Our results show that
laypeople and orthodontists perceived slight to moderate changes between the posttreatment and longterm follow-up profiles (ie, both groups saw significant changes). Although many significant
differences between males and females were found
cephalometrically, on the basis of amount of change
perceived, neither orthodontists nor laypeople
seemed to consistently pick up on sex differences in
the profile changes on the photos. Could it be that
what we measure on cephalograms for diagnostic
purposes is not what we, and laypeople, actually pay
attention to when evaluating everyday profiles of
random patients? Moreover, there does not appear to
be any relationship between changes perceived in the
profile photos and those measured cephalometrically.
A weak correlation was identified between total
facial convexity (N-Pn-Pg) and the change per-

American Journal of Orthodontics and Dentofacial Orthopedics

October 2005

ceived by orthodontists; this simply indicates that the

orthodontists noticed a difference as the profile
straightened. The results clearly showed that everyone saw changes in the profiles, but the patients
perceived to change the most were not the same ones
who had the greatest cephalometric changes. This
again supports the notion that people look beyond
traditional cephalometric profile measures when
making judgments about facial appearance.
The proportions of those who preferred the posttreatment and long-term follow-up profiles were very
similar for all groups. On average, none of the profile
choices (posttreatment, long-term follow-up, or neither) were preferred over the others. Orthodontists
and laypeople showed similar preferences with similar patterns of variation, as previously reported.6,23
There were clear preferences for certain profiles over
others, and, for certain patients, there was agreement
among orthodontists and laypeople concerning preferences. These preferences were not related to the
changes that were actually perceived. The laypeople
tended to prefer the long-term photos, and the
orthodontists leaned toward the posttreatment photos, but neither was statistically significant. Lines et
al26 reported that laypeople and orthodontists preferred straighter profiles for males and more convex
profiles for females. Because the male profiles in our
sample were significantly straighter at long-term
follow-up than the female profiles, this might explain
why no significant differences in the preferences
between males and females were noted.
Because there was no clear relation between
treatment modality and the profile preferences of
orthodontists and laypeople, it cannot be concluded
that 1 type of treatment produces better, or worse,
long-term profiles than the other. Variability of
profile preference is sufficient to support any bias.
For example, there was a nonextraction patient for
whom most evaluators preferred the posttreatment
profile. On the other hand, there was an extraction
patient whose appearance clearly improved over time
according to both orthodontists and laypeople. This
simply demonstrates that some profiles changed for
the better, and some changed for the worse. Whether
teeth were extracted had no bearing on whether the
profiles got better or worse. Boley et al27 also
showed that dental professionals could determine
only 50% of the time whether a patient was treated
with extractions. We, as orthodontists, cannot determine whether a patient will age for the better or for
the worse. The results also showed that just because
ones appearance changes over time does not necessarily mean that it will get worse or better.

Stephens et al 457

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 128, Number 4

CONCLUSIONS

1. Extraction and nonextraction patients treated to the

same incisor position and lip line were also similar
in these respects at long-term follow-up, demonstrating that the long-term posttreatment changes
were not due to the type of treatment.
2. Significant long-term changes were seen in profiles
between 15 and 30 years of age, resulting in relative
retrusion of the lips in relation to the E- and S-lines.
Because there was no significant long-term change
in lip fullness measured by the H-line, which is
independent of the nose, the changes must have
been mainly due to increased growth in the nose
and chin.
3. Although there were no significant posttreatment differences, males showed greater long-term changes
than females because of normal sexual dimorphism
in aging of the soft tissue profile, especially in the
nose and chin.
4. Small-to-moderate changes in profile were perceived during the long-term follow-up period. The
amounts of change perceived by orthodontists and
laypeople were not different, and there was no
significant correlation between changes perceived
and those measured cephalometrically.
5. There was no pattern of profile preferences among
orthodontists or laypeople. Although clear preferences were expressed for 87% of the profiles, there
were no significant findings to indicate what was
actually guiding those choices.
REFERENCES
1. Case CS. The question of extraction in orthodontia. Dent Cosmos
1912;54:137-57, 276-84.
2. Dewel BF. The Case-Dewey-Cryer extraction debate: a commentary. Am J Orthod 1964;50:862-5.
3. Paquette DE, Beattie JR, Johnston LE. 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.
4. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial
and soft tissue changes in Class II, Division 1 cases treated with
and without extractions. Am J Orthod Dentofacial Orthop 1995;
107:28-37.
5. Bishara SE, Cummins DM, Zaher AR. Treatment and posttreatment changes in patients with Class II, Division 1 malocclusion
after extraction and nonextraction treatment. Am J Orthod
Dentofacial Orthop 1997;111:18-27.
6. Bowman SJ, Johnston LE. The esthetic impact of extraction and
nonextraction treatment on Caucasian patients. Angle Orthod
2000;70:3-10.
7. Zierhut EC, Joondeph DR, rtun J, Little RM. Long-term profile
changes associated with successfully treated extraction and

8.

9.
10.

11.

12.

13.
14.

15.
16.
17.

18.

19.

20.

21.

22.

23.
24.

25.

26.
27.

nonextraction Class II Division 1 malocclusions. Angle Orthod

2000;70:208-19.
Bishara SE, Jakobsen JR. Profile changes in patients treated with
and without extractions: assessments by lay people. Am J Orthod
Dentofacial Orthop 1997;112:639-44.
Nanda RS, Meng H, Kapila S, Goorhuis J. Growth changes in the
soft tissue facial profile. Angle Orthod 1990;60:177-90.
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.
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.
Riolo ML, Moyers RE, McNamara JA, Hunter WS. An atlas of
craniofacial growth, monograph 2. Craniofacial Growth Series.
Ann Arbor: Center for Human Growth and Development; University of Michigan; 1974.
Daskalogiannakis J. Glossary of orthodontic terms. Chicago:
Quintessence Books; 2000.
Hsu BS. Comparisons of the five analytic reference lines of the
horizontal lip position: their consistency and sensitivity. Am J
Orthod Dentofacial Orthop 1993;104:355-60.
Subtelny JD. The soft-tissue profile, growth and the treatment
changes. Angle Orthod 1961;31:105-22.
Finnoy JP, Wisth PJ, Boe OE. Changes in soft tissue profile during
and after orthodontic treatment. Eur J Orthod 1987;9:68-78.
Skinazi GL, Lindauer SJ, Isaacson RJ. Chin, nose, and lips:
normal ratios in young men and women. Am J Orthod Dentofacial Orthop 1994;106:518-23.
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.
Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-tissue
profile changes: a study of three analyses. Am J Orthod 1985;
88:209-23.
Bishara SE, Jakobsen JR, Angelakis D. Posttreatment changes in
male and female patients: a comparative study. Am J Orthod
Dentofacial Orthop 1996;110:624-9.
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.
Formby WA, Nanda RS, Currier GF. Longitudinal changes in the
adult facial profile. Am J Orthod Dentofacial Orthop 1994;105:
464-76.
De Smit A, Dermaut L. Soft-tissue profile preference. Am J
Orthod 1984;86:67-73.
Rushing SE, Silberman SL, Meydrech EF, Tuncay OC. How
dentists perceive the effects of orthodontic extraction on facial
appearance. J Am Dent Assoc 1995;126:769-72.
Cochrane SM, Cunningham SJ, Hunt NP. A comparison of the
perception of the facial profile by the general public and 3 groups
of clinicians. Int J Adult Orthod Orthognath Surg 1999;14:291-5.
Lines PA, Lines RR, Lines CA. Profilemetrics and facial esthetics. Am J Orthod 1978;73:648-57.
Boley JC, Pontier JP, Smith S, Fulbright M. Facial changes in
extraction and nonextraction patients. Angle Orthod 1998;68:53946.