Journal of the World Federation of Orthodontists 2 (2013) e175ee179

Contents lists available at ScienceDirect

Journal of the World Federation of Orthodontists

journal homepage: www.jwfo.org

Research

Interlabial gap behavior with time

Guilherme Janson a, *, Patrcia Bittencourt Dutra dos Santos b, Daniela Gamba Garib c,
Manoela Fvaro Francisconi d, Taiana de Oliveira Baldo e, Srgio Estelita Barros f
a
Member, Royal College of Dentists of Canada; Professor, Department of Orthodontics, Bauru Dental School, University of So Paulo, Bauru, Brazil
b
Orthodontic Graduate Student, Department of Orthodontics, Bauru Dental School, University of So Paulo, Bauru, Brazil
c
Associate Professor, Department of Orthodontics, Hospital of Rehabilitation of Craniofacial Anomalies, Bauru, Brazil; Bauru Dental School, University of
So Paulo, Bauru, Brazil
d
Orthodontic Graduate Student, Department of Orthodontics, Bauru Dental School, University of So Paulo, Bauru, Brazil
e
Private Practice, So Paulo, Brazil
f
Associate Professor, Department of Orthodontics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Background: The purpose of this study was to evaluate the long-term behavior of the interlabial gap in
Received 7 July 2013 patients with Class I and Class II malocclusion after orthodontic treatment and to investigate whether
Received in revised form interlabial gap behavior is related to treatment with or without extraction.
25 September 2013
Methods: Lateral head-lms at the pre- and post-treatment and long-term follow-up stages were
Accepted 2 November 2013
Available online 2 December 2013
obtained from 61 patients who initially had Class I or Class II malocclusion and with pre- and post-
treatment lip incompetence, who were treated with or without extraction. Dependent and indepen-
dent Students t tests were used for the intra- and intergroup comparisons.
Keywords:
Cephalometry
Results: There were signicant interlabial gap reductions of 1.64 and 1.72 mm in Class I and II, respec-
Lip tively, but there was no signicant intergroup difference. Nonextraction patients had signicantly greater
Tooth extraction interlabial gap reduction (2.7 mm) than did extraction patients (1.3 mm) in the long-term.
Conclusions: It was concluded that the interlabial gap decreases signicantly and similarly in treated Class
I and Class II malocclusion patients and that nonextraction treatment has greater interlabial gap
reduction than does extraction treatment in the long-term post-treatment period.
2013 World Federation of Orthodontists.

1. Introduction incompetence and malocclusion [8e12] and soft tissue features

During the past decade, great concern has been drawn toward
facial esthetics as one of the major goals of orthodontic treatment
[1,2]. Consequently, evaluation of lip posture features is a require-
ment for achieving pleasant facial harmony [3e5]. Before ortho-
dontic treatment, clinical assessment should always include
evaluation of the soft tissue at rest and during function because
morphology of the soft tissues is a major factor in determining the
overall facial prole [6].
In normal occlusion or at the end of treatment, a normal
vertical-lips relationship should consist of a mean gap of 2 mm
(
2 mm), with the mandible in centric occlusion [7]. Therefore, a
small amount of lip incompetence is considered to be normal. A
number of studies have described the relationship between lip
* Corresponding author: Department of Orthodontics, Bauru Dental School,
University of So Paulo, Alameda Octvio Pinheiro Brisolla 9-75, Bauru - SP - 17012-
901, Brazil.
E-mail address: jansong@travelnet.com.br (G. Janson).
[13]. Among the factors most related to lip incompetence are lip
lengths [9,13e15], facial patterns [16e18], and teeth positions
[10,13,19,20]. However, no study has described how the interlabial
gap changes after orthodontic treatment.
Therefore, the purpose of this study was to evaluate the long-
term behavior of the interlabial gap in Class I and Class II maloc-
clusion patients after orthodontic treatment and to investigate
whether lip competence is related to lip length, facial pattern, and
treatment with or without extraction.
2. Methods and materials
The sample size of each group was calculated based on an alpha
signicance level of 0.05 and a beta of 0.2 to achieve 80% of power
to detect a mean difference of 1.5 mm in interlabial gap change
between the post-treatment and the long-term post-treatment
interlabial gap, with a 2.0 mm of estimated SD. The sample size
calculation showed that 29 patients in each group were needed,
and to increase the power even more it was decided to select 30 and
31 patients with Class I and II malocclusion, respectively.

2212-4438/$ e see front matter 2013 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2013.11.001
e176 G. Janson et al. / Journal of the World Federation of Orthodontists 2 (2013) e175ee179

The sample was retrospectively selected from the les of the

Orthodontic Department at Bauru Dental School, University of
So Paulo, Bauru, Brazil, which consists of more than 4000 treated
patients. Records of all patients who initially had pre- and post-
treatment lip incompetence, with the lips relaxed and in centric
occlusion, were selected and divided into two groups. Sample se-
lection was based exclusively on the lateral head-lms.
The Class I group consisted of 30 patients (20 female, 10 male)
who initially had Class I malocclusion, with a mean age of
15.21 years at the end of treatment and 21.87 years at the long-term
post-treatment stage. Class II consisted of 31 patients (24 female, 7
male) who initially had Class II Division 1 malocclusion, with a mean
age of 15.88 years at the end of treatment and 22.67 years at the
long-term post-treatment stage. The long-term observation times
were 6.66 and 6.79 years in Class I and II, respectively (Table 1).
Lateral cephalograms were evaluated to determine lip incom-
petence, lip length, and facial pattern as determined by the Frank-
furt mandibular plane angle (Figs. 1 and 2). The cephalometric
tracings and landmark identications were performed on acetate
paper by one investigator (P.B.D.d.S.) and then digitized with a
Numonics Accugrid XNT digitizer (Houston Instruments, Austin,
TX). These data were stored in a computer and analyzed using
Dentofacial Planner version 7.02 (Dentofacial Planner Software,
Toronto, Ontario, Canada). Linear and angular measurements were
performed. Information about rst-premolar extraction was ob- Fig. 1. Linear measurements. 1, upper lip length; 2, interlabial gap; 3, lower lip length.
tained from each patients clinical records.
Interlabial gap behavior with time was evaluated on the lateral All statistical analyses were performed with Statistica for Win-
head-lms between the post-treatment and the long-term post- dows 7.0 (Statsoft, Tulsa, OK).
treatment stages.
3. Results and discussion
2.1. Error study
None of variables showed statistically signicant systematic
Twenty randomly selected patients from both groups had their errors, and the random errors varied from 0.14 (long-term post-
radiographs retraced, redigitized, and remeasured by the same treatment interlabial gap) to 1.70 (lower lip length). The groups
examiner. The random error was calculated according to Dahlbergs were compatible regarding the post-treatment and long-term post-
formula [21]. The systematic errors were evaluated with dependent treatment ages, and the long-term post-treatment time (Table 1).
Students t tests at P < 0.05 [22,23]. The interlabial gap decreased 1.64 mm with time in treated Class
I malocclusion patients and 1.72 mm in treated Class II malocclusion
patients, which were statistically signicant within the groups.
2.2. Statistical analyses
However, there was no signicant intergroup difference regarding
these changes (Table 2).
Means and SDs were calculated for all cephalometric variables in
Of all variables, only the treatment with or without extraction
each group. Normal distribution was veried by Kolmogorov-
was signicantly associated with interlabial gap behavior, according
Smirnov tests. The results were nonsignicant for all variables.
to the multiple regression analysis (Table 3). Because of this result,
Intergroup comparison of the post-treatment and long-term
interlabial gap changes between nonextraction and extraction pa-
post-treatment ages and the long-term post-treatment times
tients of the groups were compared. The nonextraction treatment
were performed with Students t tests.
had an interlabial gap reduction of 2.73 mm, which was signi-
Dependent Students t tests were used to evaluate the within-
cantly greater than the 1.31-mm reduction of the extraction treat-
group interlabial gap behavior with time. Students t tests were
ment (Table 4).
used to evaluate intergroup differences regarding the post-
treatment and long-term post-treatment interlabial gap, and the
3.1. Sample selection
long-term interlabial gap post-treatment changes. Multiple linear
regression analysis was used to assess the relationship between lip
The inclusion of only 61 patients from the available 4000 might
length, facial pattern, and treatment with or without extraction and
seem small. This was because of the rigid selection criteria, espe-
interlabial gap behavior.
cially that the patients should present with pre- and post-treatment
lip incompetence, with relaxed lips and in centric occlusion, and
Table 1 that the necessary records were available or could be obtained.
Post-treatment and long-term post-treatment ages, and long-term post-treatment Additionally, some patients were not included to match the groups
times
for the several factors described.
Parameter Class I (n 30) Class II (n 31) P*
Post-treatment age 15.21 (1.86) 15.88 (1.75) 0.154 3.2. Methodology
Long-term post-treatment age 21.87 (2.79) 22.67 (3.53) 0.332
Long-term post-treatment time 6.66 (2.77) 6.79 (2.83) 0.854 Interlabial gap was evaluated with the lips in a relaxed position
Data are presented as mean (SD) years. and with the mandible in centric occlusion. In centric occlusion, a
* t Test. lips-relationship with an interlabial gap of 2 mm (
2 mm) is
 G. Janson et al. / Journal of the World Federation of Orthodontists 2 (2013) e175ee179 e177

Fig. 2. Angular measurement (facial pattern). 1, Frankfurt-mandibular plane angle.

accepted to be normal [7]. When the lips are apart, it is also
considered as lip incompetence [13]. Therefore, a mean of 2 mm of
lip incompetence is accepted as normal. All of the evaluated pa-
tients in this investigation had to present with an interlabial gap at
the post-treatment stage. Both groups at the post-treatment stage
had a mean within the accepted normal range (Table 2). Therefore,
the behavior of the normal interlabial gap in treated patients could
be investigated.
To our knowledge, this study is unique in that it is the rst
attempt to evaluate the long-term behavior of the interlabial gap in
patients who had orthodontic treatment. A number of methods to
evaluate lip-sealing ability have been reported: visual examination
[24], facial photography, cephalometric radiography [25], pressure-
distribution sensor [26], and electromyographic activity [27].
Cephalometric radiography was used in this study because it is the
choice of many researches evaluating the soft tissue prole
[3e5,28e36].
3.3. Groups compatibility
The groups were similar regarding the post-treatment and long-
term post-treatment ages, and the long-term post-treatment times
(Table 1). Some subjects from both groups had to be eliminated to
match the ages.
3.4. Interlabial gap behavior with time
The interlabial gap signicantly decreased with time in both
groups (Table 2). Comparisons of the results with other studies
should be made with caution because there are no reports on

Table 2 Table 3
Interlabial gap behavior with time in Class I and II malocclusions Relationship between the lip length, facial pattern, and extraction and interlabial gap
behavior*
Parameter Class I Class II P between
(n 30) (n 31) classes* Variable P for interlabial gap behavior
Post-treatment interlabial gap 2.65 (1.66) 3.13 (1.53) 0.246 Upper lip length 0.546
Long-term post-treatment interlabial gap 1.00 (2.21) 1.40 (1.98) 0.183 Lower lip length 0.958
Py between time points 0.001 <0.001 e Facial pattern 0.472
Interlabial gap change 1.64 (2.51) 1.72 (2.12) 0.894 Treatment with or without extraction 0.028y
Groups 0.785
Data are presented as mean (SD) millimeters.
* t Test. * Multiple linear regression; r 0.313; R2 0.0984.
y y
Dependent t test; statistically signicant at P < 0.05. Statistically signicant at P < 0.05.
e178 G. Janson et al. / Journal of the World Federation of Orthodontists 2 (2013) e175ee179
Table 4
Comparison of interlabial gap changes between nonextraction and extraction
treatment
Variable Nonextraction (n 16) Extraction (n 45)
Interlabial gap change 2.73 (1.53) 1.31 (2.42)
Data are presented as mean (SD) millimeters.
* Statistically signicant at P < 0.05.
interlabial gap behavior with time in the literature. However,
different aspects of lip behavior with time have been reported. Lip
retrusion and decrease in lip thickness cause interlabial gap
reduction [3,4,31]. Long-term observation studies have shown a
decrease in lip thickness and greater lip retrusion which are
explained by the loss of subcutaneous tissue with age [37] or as a
consequence of changes in muscle tonus in the perioral area
[3,4,17,31]. Therefore, these factors may partially explain the
observed interlabial gap reduction.
3.5. Interlabial gap behavior between Class I and Class II
malocclusions
Several studies have assessed the relationship between interla-
bial gap and malocclusion. Among the occlusal conditions most
associated to lip incompetence are over jet, mandibular incisor
inclination, and anteroposterior discrepancies [10e12]. This means
that different occlusal conditions for different types of malocclusion
can be related to interlabial gap. However, no research has assessed
the relationship between malocclusion and interlabial gap behavior
with time, after orthodontic treatment. Consequently, any com-
parison to other research is fairly limited. In this study, patients
who initially had Class I and Class II malocclusions and pretreat-
ment lip incompetence were included. At the end of orthodontic
treatment, these patients still had lip incompetence and showed
the same interlabial gap behavior with time, regardless of the initial
malocclusion (Table 2). Therefore, independently of the initial
malocclusion, one can expect the same changes in interlabial gap
after orthodontic treatment, with time. In fact, this would be ex-
pected because at the end of treatment, both groups nished with a
normal occlusion and consequently the changes should be similar if
there were no signicant relapses in the groups. Primarily, it would
be over jet relapse in the Class II malocclusion group that could be
accounted for some intergroup difference. However, because there
were no intergroup differences in interlabial gap behavior with
time, this indirectly suggests that there were no signicant relapses
in over jet in the Class II group. Therefore, the initial occlusal factors
of the different malocclusions no longer have an effect.
3.6. Factors associated with interlabial gap behavior
Although investigations have shown signicant relationships
between interlabial gap amount, lip length [3,31], and facial pattern
[38], the present results show that these variables have no inuence
on interlabial gap behavior with time (Table 3). Therefore, it seems
that lip lengths and facial pattern are related only to the amount of
interlabial gap; however, there is no inuence on interlabial gap
behavior with time. The only variable associated with interlabial
gap behavior with time, in the multiple linear regression analysis,
was the treatment protocol whether conducted with or without
extraction; this topic will be discussed subsequently.
3.7. Interlabial gap behavior between nonextraction and extraction
treatment
The interlabial gap decreased signicantly more in the non-
extraction than in the extraction patients, with time (Table 4). There
are no reports that have assessed the relationship between inter-
labial gap behavior with time and nonextraction and extraction
treatment. However, several studies have reported the relationship
P between interlabial gap behavior during orthodontic treatment
0.024* [30,36,39e42]. Extraction treatment causes greater interlabial gap
reduction during treatment than does nonextraction treatment
[36]. This is probably consequent to the incisor retraction that
usually occurs during extraction mechanics. As the incisors retract,
the lips usually follow and consequently approximate to each other,
decreasing the interlabial gap. This mechanism is absent in Class I
nonextraction treatment and is partially present in Class II non-
extraction treatment during correction of the anteroposterior
discrepancy. During the long-term post-treatment period, the
amount of interlabial gap decrease is greater in nonextraction
treatment due to the natural changes with growth and develop-
ment. It seems that the interlabial gap behaves similarly to other
variables when submitted to orthodontic treatment [39e41]. The
greater the changes during treatment, the smaller post-treatment
changes will be [42].
3.8. Clinical implications
Obtaining an adequate vertical-lip relationship is an objective to
be attained at the end of orthodontic treatment [10,11,43]. Usually,
this required retraction of the incisors and, concurrently, of the lips.
However, long-term post-treatment observational studies later
showed that for some time, there was excessive retraction of the
incisors and consequently of the lips, leading to an excessively at
prole in late adult life [19,28,36,41,42,44e46]. Therefore, accep-
tance of a more protruded prole during adolescence started to
guide the excellence for a more attractive prole at the end of or-
thodontic treatment [47]. As a more protruded prole can be
accepted in adolescence, it is possible that some amount of inter-
labial gap may also be accepted because these features are inter-
related [10,43]. This can be accepted within a certain range because
this study showed that there is a reduction in interlabial gap with
time either in nonextraction and extraction cases. The reduction in
interlabial gap was signicantly greater in the nonextraction than in
the extraction cases. To a certain extent, this reinforces the current
tendency toward nonextraction treatment. Therefore, nowadays, it
is perfectly possible to nish the cases with some lip protrusion
either associated or not with some interlabial gap in adolescent
patients because there will be a natural reduction in protrusion and
in the interlabial gap in the long-term. One has to be aware of these
soft tissue changes in the long-term because they will play a very
important role in a patients future facial esthetics.
4. Conclusions
The decrease over time in interlabial gap was signicant in both
Class I and II, but the change was similar between the two groups.
Nonextraction treatment had greater interlabial gap reduction than
did extraction treatment in the long-term post-treatment period.
Acknowledgment
The authors would like to acknowledge FAPESP (So Paulo State
Research Foundation) for its Support. Process #09/06927-3 So
Paulo, Brazil.
References
[1] Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment
planningdPart II. Am J Orthod Dentofacial Orthop 1993;103:395e411.
[2] Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment
planning. Part I. Am J Orthod Dentofacial Orthop 1993;103:299e312.
 G. Janson et al. / Journal of the World Federation of Orthodontists 2 (2013) e175ee179
[3] Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-tissue prole changes: a
study of three analyses. Am J Orthod 1985;88:209e23.
[4] Bishara SE, Peterson LC, Bishara EC. Changes in facial dimensions and re-
lationships between the ages of 5 and 25 years. Am J Orthod 1984;85:238e52.
[5] Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am J
Orthod Dentofacial Orthop 1994;106:175e86.
[6] Subtelny JD. The soft tissue prole, growth and treatment changes. Am J
Orthod 1961;31:105e22.
[7] Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic
surgery. J Oral Surg 1980;38:744e51.
[8] Haynes S. Prevalence of upper lip posture and incisor overjet. Community
Dent Oral Epidemiol 1977;5:87e90.
[9] Ingervall B, Eliasson GB. Effect of lip training in children with short upper lip.
Angle Orthod 1982;52:222e33.
[10] Simpson MM. Lip incompetence and its relationship to skeletal and dental
morphologydan electromyographic investigation. Br J Orthod 1976;3:177e9.
[11] Ueda K, Motegi E, Yata R, et al. Lip seal study of Japanese adults with
malocclusion. Bull Tokyo Dent Coll 2002;43:89e93.
[12] Yata R, Motegi E, Ueda K, et al. A lip seal study of Japanese children with
malocclusion. Bull Tokyo Dent Coll 2001;42:73e8.
[13] Burstone CJ. Lip posture and its signicance in treatment planning. Am J
Orthod 1967;53:262e84.
[14] Frankel R. Lip seal training in the treatment of skeletal open bite. Eur J Orthod
1980;2:219e28.
[15] Vig PS, Cohen AM. Vertical growth of the lips: a serial cephalometric study.
Am J Orthod 1979;75:405e15.
[16] Hartgerink DV, Vig PS. Lower anterior face height and lip incompetence do not
predict nasal airway obstruction. Angle Orthod 1989;59:17e23.
[17] Ricketts RM. Planning treatment on the basis of the facial pattern and an
estimate of its growth. Angle Orthod 1957;27:14e37.
[18] Tomiyama N, Ichida T, Yamaguchi K. Electromyographic activity of lower lip
muscles when chewing with the lips in contact and apart. Angle Orthod
2004;74:31e6.
[19] Jacobs JD. Vertical lip changes from maxillary incisor retraction. Am J Orthod
1978;74:396e404.
[20] Wholley CJ, Woods MG. Tooth and lip responses to three commonly pre-
scribed premolar extraction sequences: a review of recent research ndings.
Aust Orthod J 2004;20:115e21.
[21] Dahlberg G. Statistical methods for medical and biological students. New York,
NY: Interscience; 1940.
[22] Gravely JF, Benzies PM. The clinical signicance of tracing error in cepha-
lometry. Br J Orthod 1974;1:95e101.
[23] Houston WJ. The analysis of errors in orthodontic measurements. Am J Orthod
1983;83:382e90.
[24] Drevensek M, Papic JS. The inuence of the respiration disturbances on the
growth and development of the orofacial complex. Coll Antropol 2005;29:
221e5.
[25] Flores-Mir C, Major PW. A systematic review of cephalometric facial soft tissue
changes with the Activator and Bionator appliances in Class II division 1
subjects. Eur J Orthod 2006;28:586e93.
[26] Umemori M, Sugawara J, Kawauchi M, Mitani H. A pressure-distribution
sensor (PDS) for evaluation of lip functions. Am J Orthod Dentofacial Orthop
1996;109:473e80.
[27] Yamaguchi K, Morimoto Y, Nanda RS, Ghosh J, Tanne K. Morphological dif-
ferences in individuals with lip competence and incompetence based on
electromyographic diagnosis. J Oral Rehabil 2000;27:893e901.
e179
[28] 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;107:28e37.
[29] Bishara SE, Cummins DM, Zaher AR. Treatment and post-treatment
changes in patients with Class II, Division 1 malocclusion after extraction
and nonextraction treatment. Am J Orthod Dentofacial Orthop 1997;111:
18e27.
[30] Bishara SE, Jakobsen JR. Prole changes in patients treated with and without
extractions: assessments by lay people. Am J Orthod Dentofacial Orthop
1997;112:639e44.
[31] Bishara SE, Jakobsen JR, Hession TJ, Treder JE. Soft tissue prole changes from
5 to 45 years of age. Am J Orthod Dentofacial Orthop 1998;114:698e706.
[32] de Freitas LM, de Freitas KM, Pinzan A, Janson G, de Freitas MR. A comparison
of skeletal, dentoalveolar and soft tissue characteristics in white and black
Brazilian subjects. J Appl Oral Sci 2010;18:135e42.
[33] de Freitas LM, Pinzan A, Janson G, et al. Facial height comparison in young
white and black Brazilian subjects with normal occlusion. Am J Orthod Den-
tofacial Orthop 2007;131:706.e1e6.
[34] Gjorup H, Athanasiou AE. Soft-tissue and dentoskeletal prole changes asso-
ciated with mandibular setback osteotomy. Am J Orthod Dentofacial Orthop
1991;100:312e23.
[35] Paquette DE, Beattie JR, Johnston Jr LE. A long-term comparison of non-
extraction and premolar extraction edgewise therapy in borderline Class II
patients. Am J Orthod Dentofacial Orthop 1992;102:1e14.
[36] Stephens CK, Boley JC, Behrents RG, Alexander RG, Buschang PH. Long-term
prole changes in extraction and nonextraction patients. Am J Orthod Den-
tofacial Orthop 2005;128:450e7.
[37] Hellman M. The face in its development career. Dent Cosmos
1935;77:658e99.
[38] Blanchette ME, Nanda RS, Currier GF, Ghosh J, Nanda SK. A longitudinal
cephalometric study of the soft tissue prole of short- and long-face syn-
dromes from 7 to 17 years. Am J Orthod Dentofacial Orthop 1996;109:
116e31.
[39] Yogosawa F. Predicting soft tissue prole changes concurrent with ortho-
dontic treatment. Angle Orthod 1990;60:199e206.
[40] Hodges A, Rossouw PE, Campbell PM, et al. Prediction of lip response to four
rst premolar extractions in white female adolescents and adults. Angle
Orthod 2009;79:413e21.
[41] Erdinc AE, Nanda RS, Dandajena TC. Prole changes of patients treated with
and without premolar extractions. Am J Orthod Dentofacial Orthop
2007;132:324e31.
[42] Zierhut EC, Joondeph DR, Artun J, Little RM. Long-term prole changes asso-
ciated with successfully treated extraction and nonextraction Class II Division
1 malocclusions. Angle Orthod 2000;70:208e19.
[43] de Oliveira DS, Atherino CC, Cervasio MR, et al. Lip incompetence and psy-
chosocial effects: a pilot study. Laryngoscope 2007;117:1245e50.
[44] Klapper L, Navarro SF, Bowman D, Pawlowski B. The inuence of extraction
and nonextraction orthodontic treatment on brachyfacial and dolichofacial
growth patterns. Am J Orthod Dentofacial Orthop 1992;101:425e30.
[45] Bravo LA. Soft tissue facial prole changes after orthodontic treatment with
four premolars extracted. Angle Orthod 1994;64:31e42.
[46] Rains MD, Nanda R. Soft-tissue changes associated with maxillary incisor
retraction. Am J Orthod 1982;81:481e8.
[47] Sforza C, Laino A, DAlessio R, et al. Soft-tissue facial characteristics of
attractive and normal adolescent boys and girls. Angle Orthod 2008;78:
799e807.