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3
Chapter

Diagnosis and treatment planning

Nigel Harradine
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Introduction
The chapter on Occlusal Treatment Goals considers what our occlusal goals should be. This chapter
addresses further important questions of diagnosis and treatment planning:

• where would we ideally like to place this occlusion horizontally and vertically within the face?
• exactly what aspects of the appearance and function of the teeth and face are a source of
dissatisfaction to the patient?
• what are the diagnostic features, which we need to observe to decide how we can find the
best means of satisfying these requirements?
• how do extractions affect aesthetics, stability and ease of treatment?

With regard to the first point, the vertical position of the occlusion is also important to remember and we
should ensure that our treatment mechanics avoid unwanted extrusion of the molars or incisors. The
scope for altering the vertical position of the occlusion orthodontically is covered in other chapters. This
chapter will discuss the antero-posterior position of the occlusion and to a lesser extent, the width of the
occlusion. Decisions need to be reached as to what is desirable and what is achievable.

In relation to the second point, a gummy smile is a good example of a dentofacial feature which may bother
us but not the patient.

A list of diagnostic features relating to these aspects is clearly required and also decisions about how best
to assess them.

The last part of this chapter focuses on extraction decisions, which are such an important part of the
planning process.

Features important in diagnosis

It is inappropriate in this manual to deal in detail with all the potentially relevant features, such as
measuring the overjet or assessing the molar relationship. Nor is a level of detail appropriate for
orthognathic cases included here. Rather, this section is a core checklist to avoid important categories of
data being neglected and to suggest appropriate measures in some categories.

The occlusion
Important aspects of occlusal planning have been covered in the chapter on Occlusal Treatment Goals.
However, other factors, notably dental disease or missing or previously extracted teeth will alter the
potential choice of occlusal goals.

The facial soft-tissue profile

The two most important features are probably the prominence of the lips relative to the nose and chin
(assessed via the lower lip to E line distance or using Merrifield’s line) and the nasolabial angle (NLA).
These have their limitations but are also quick and easy to apply and therefore stand a good chance of
being incorporated in routine orthodontic diagnosis. One of the limitations of the NLA is that it comprises
both the angle of the lower surface of the nose and also the inclination of the upper lip and facial aesthetics
in profile may be more influenced by the latter. An angle between a tangent to the upper lip and the facial
horizontal might be a better measure of this feature but is not in common use and the NLA with intelligent
interpretation may therefore be preferred.

The Holdaway angle is another well-known measure of balance in facial profile. It has recently been used
in the British Orthodontic Society national audit of successively treated orthognathic cases and is now
officially recommended by the BOS clinical effectiveness committee as one of seven cephalometric
measures to audit the outcome of orthognathic cases. OPAL-Image, which is produced on behalf of the
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BOS, was used to measure and extract the data and the
Holdaway angle is now included in the OPAL analysis in
OPAL-Image 2.0 and 2.1. This angle is open to a little
confusion both from differences in definition and also
depending on whether the correction factor for the skeletal
convexity is applied. The original papers (Holdaway 1983,
Holdaway 1984), fully explain his thoughts with plenty of
examples. The norm is entirely his opinion. A paper by
Basciftci et al (2003) used this angle and is a good
example of the angle in action as a measure of balance in
facial profile. The angle in its conventional definition is
between soft tissue nasion-soft pogonion and soft
pogonion-labrale superius. The larger the facial convexity
(i.e. the more skeletal class 2), the larger the angle should
be, according to Holdaway. Interestingly, both the Turkish
dental students in this paper and the Bolton norms have
Holdaway angles at the very upper end of ‘normal’
according to Holdaway. OPAL-Image 2.1 gives both the
Figure 3.1: The Holdaway angle. A measure of uncorrected value and the value corrected for convexity
facial balance which excludes the nose according to Holdaway’s formula. An important point about
Merrifield’s line and the Holdaway angle are that they do
not include nose prominence in the assessment of facial balance whereas the Rickets E line does.

A recent, relatively straightforward and interesting analysis for assessing soft tissue balance has been
proposed by Bass (2003). The antero-posterior positions of the lips and chin are assessed in relation to a
perpendicular from subnasale. This analysis is linear as is Ricketts E line assessment but like the
Holdaway analysis, disregards the nose. An appealing aspect is the use of a natural vertical obtained from
posing during a lateral photograph, which is then transferred to the cephalometric x-ray. This uses a
simple protractor and the E line as a reference common to photograph and cephalogram. A simple method
of recording natural head posture is intuitively a sensible way to view aesthetics of the soft tissues. Some
digitising programs such as OPAL, permit the recording of natural vertical and then make antero-posterior
measurements - e.g. of the nose and chin - in relation to it. This method may increase the popularity of
using a natural head posture.

The lips
The vertical resting and smiling (upper lip) lip lines are important in relation to appearance and in some
cases to the stability of overjet reduction. These can be measured in mm relative to the upper incisor tip. If
any upper gum is shown during smiling, this may be a cause of concern to the patient and this possibility
should be explored. Interestingly, Johnson and Smith (1995) propose, in a study on smile width, that the
most important feature of a smile that both affects aesthetics and is also affected by orthodontics, is the
amount of maxillary gingivae displayed. Their examples of smiles judged to have a poor appearance by a
lay panel seem to support this view.

The A-P and vertical skeletal pattern and the incisor inclinations
A well-known variety of cephalometric parameters exist for these assessments.

Temporomandibular joint dysfunction

Although clinically significant signs and symptoms seem uncommon and there is good evidence that
orthodontic treatment does not cause this potential problem, it is quick and easy to at least be aware of the
existence and extent of any signs and symptoms.

• joint noises?
• discomfort with jaw movement / muscle tenderness?
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• amount of opening and lateral excursion in mm. This can be recorded in the notes in simple
diagrammatic form and is a good objective sign of a change in actual joint dysfunction.
Opening is usually > 40 mm and lateral excursion > an upper incisor width.

The patient's actual complaints

For example: Is the patient bothered by the prominent upper teeth or also by the receding chin? This may
profoundly affect the chosen plan in cases of borderline skeletal severity. Is the patient bothered by the
appearance or function of an anterior open bite or is it the long face or the gummy smile that are the main
concern? This may strongly influence the choice between Young Kim type orthodontic mechanics and a Le
Fort osteotomy.

Patient compliance
The literature has to date been largely unhelpful in identifying predictors of lack of patient compliance. Mid-
treatment indicators such as a failure to attend or to progress in the early stages of treatment are of some
help, but we still have almost no scientific ability to pick winners in advance. The study by O’Brien et al
(2003) did show that a geographical measure of likely social deprivation (the postcode) did significantly
predict levels of compliance with functional appliances. However, it is debatable as to how much we would
alter the treatment plan in the light of the patient’s address.

Age and sex

Spontaneous space closure has been clearly shown by Stephens to be highly related to the rate and
amount of remaining growth. Johnston has shown (e.g. Livieratos and Johnston 1995) in studies using his
pitchfork analysis (Johnston 1996) that in a growing patient, a significant part of the correction of a class 2
molar relationship in a non-extraction case is, on average, due to temporary inhibition of maxillary growth
and continuing mandibular growth. This is clearly a large factor to consider when choosing mechanics in a
patient with little or no remaining growth.

The problem list

Having gathered all the relevant data, we would strongly advocate the compilation of a problem list before
deciding on treatment aims and subsequently, treatment means. The advantages of a problem list can be
summarised a follows:

• it turns a mass of data into a short and relevant list

• no problems are forgotten – at the treatment planning stage or later
• it focuses thought on the actual problems
• it enables problems to be recorded as fully noted, even if the subsequent list of treatment
aims includes a decision to accept a problem rather than to attempt to resolve it.

These are powerful advantages in making good plans, in keeping track of treatment aims during treatment
and in recording the limitations of treatment aims. A list of treatment aims will of necessity address all the
problems in the list and will lead to a rational selection of the best means of treatment for that patient

The sequence of forming a plan should therefore be:

1. compile a problem list

2. list the treatment aims
3. list the treatment means

General and specific treatment aims

Any specific list of treatment aims will be compiled against an underlying set of general treatment aims or
principles. For example, we need to have answers to all the following questions:
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• what final occlusion do I normally aim for?

• what general aims do I have about changes in arch width and shape?
• what do I believe is desirable/achievable regarding vertical tooth position?
• what general aims do I have for antero-posterior lower incisor position?
• what are my general views about the effects of extractions and what factors influence my
choice of extractions?

All these questions are addressed in one of the chapters of this manual, with the last two being a particular
focus of this chapter. It will not surprise readers to hear that we feel that every orthodontist needs views on
these questions that are based on the best available evidence, although it needs to be recognised that the
current evidence is far from ideal on many of these points. A paper by Lysle Johnston (1998) is typically
iconoclastic on this subject and very well worth a read. It is entitled “The value of information and the cost
of uncertainty: who foots the bill?”

Antero-posterior incisor position

This is a highly important part of any treatment plan. Given that our occlusal goals usually include a class I
incisor relationship, the question becomes one of where to aim to put the lower incisors. This should be
considered first in its own right and then in relation to extraction philosophy since this a very important
determinant of final lower incisor position. This question is very amenable to cephalometric analysis and
many well-known cephalometric goals for lower incisor position have been advocated. Those by Tweed,
Steiner, Merrifield, (1996) Ricketts, Downs, Mills (1966) and Holdaway are representative (see the book by
Athanasiou 1995). The questions that should be asked about each of these analyses or goals are:

• does it produce results that are considered more stable than other analyses?
• are the results more aesthetic than those achieved using other analyses?
• can the planned position be more easily achieved than others?
• is any cephalometric planning of incisor position quick, easy and accurate to use?
• is the planned incisor position conducive to long-term dental health?

Stability and lower incisor position

The most crucial questions are the first two. Regarding stability, few people now dispute that no treatment
goal is likely to produce more stable results than those obtained when following Mills’ goal (1968) of aiming
to leave the average incisor labiolingual position unchanged during treatment. The question is whether
other guides to end-of-treatment incisor position will produce results that are equally stable
anteroposteriorly. In the past, many have claimed or implied - contrary to Mills’ findings - that their
analysis or goal will consistently produce substantial and stable labiolingual change in lower incisor
position. The evidence to support this is very slim although individual cases of such a stable change
undoubtedly occur. Mills (1966) found that lower incisors which were proclined or retroclined by a minimum
of 7 degrees during treatment relapsed by an average of 50% post-treatment. The extent of these post-
treatment changes correlated significantly with the amount of labiolingual movement, although there were
unpredictable individual exceptions. A study by Houston and Edler (1990) provided strong evidence that
the APo line is not a position of lower incisor stability. They also found that in 62% of cases the incisors
tended to return towards their starting A-P position. In the remaining cases, the post-treatment A-P
changes were haphazard. More recent studies have produced similar findings. Hansen, Koutsonas and
Pancherz (1997) found that incisors proclined an average of 11 degrees or 3.2 mm retroclined an average
of 8 degrees or 2.5 mm in the following six months when no appliances were in place. Stucki and Ingervall
(1998) found that on average 70% of the proclination produced by Jasper Jumpers subsequently relapsed.

Sims and Springate (1995) investigated more modest A-P alterations in lower incisor position and found a
similar tendency for incisors moved labially during treatment to return towards their starting position, but
found that modest retroclination of incisors was stable or even increased post-retention. This is one of
several hints in the literature that invasion of the space previously occupied by the tongue is more stable
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than invasion of lip or cheek space. These authors also commented on the wide standard deviation of
post-treatment change around the average changes.

A study by Williams and Andersen (1995) investigated the very interesting idea that lower incisor
proclination might prove to be stable in those patients in whom the mandible is expected to develop in an
anterior rotational pattern according to the morphological features described by Bjork. The treatment would
in effect be taking advantage of the natural tendency for lower incisors to procline as the mandible rotates
anteriorly. The authors found an average proclination during treatment of 9 degrees with an average
relapse of 3.4 degrees and an average treatment change relative to APo of 2.7 mm with an average
relapse of 1.2 mm. The degree of relapse was very significantly related to the amount of labial movement
or proclination although some cases were a marked exception to the general rule. Disappointingly, anterior
rotators are no more likely to permit stable lower incisor proclination than other groups.

This paper therefore supports the previous studies, but can similarly be interpreted in two ways:

• proclination tends to be unstable

or alternatively,

• approximately 60% of the proclination remains.

Both these statements are true, but many clinicians seem to recall only one of them. Several details of the
study are worth noting. Firstly, all cases were retained until skeletal maturity (hand-wrist radiographs) - an
average of 3.3 years. Secondly, the post-retention Little’s index was much better than most of those
reported by Little (1990) (2.8 mm vs. 4.7 mm). Was this due to the long retention until cessation of growth
or is it related to the anterior growth rotation? Thirdly, the relapse in lower incisor labial movement was not
related to the relapse in Little’s index, which again proved hard to statistically attribute to any parameter
other than expansion during treatment of the intercanine width. Finally we should note that not all of those
predicted to rotate anteriorly, actually did. Also, marked pogonial growth made some cases appear to have
no linear movement of the lower incisors in spite of definite proclination relative to the mandibular plane.
An interesting paper!

Paquette et al (1992) also found that cases which had been treated with an average of 2.8 mm. more
lower incisor proclination than another matched group of cases, finished with slightly greater irregularity
(Little’s index) out of retention. The difference in post-treatment relapse of irregularity between the two
groups was very small (0.6 mm), but the findings did suggest that labial movement of lower incisors during
treatment does, on average, increase the chance of subsequent relapse.

No study has demonstrated consistent anteroposterior stability in a group of orthodontic cases in which the
lower incisors have been significantly changed in their A-P position during treatment. Reviewing current
knowledge on the ability of the soft tissues to adapt to lower arch expansion, Ackerman and Proffit (1997)
propose an approximate limit of 2 mm for labial movement of the lower incisors if antero-posterior stability
is the main factor influencing our decision.

It is of interest to detour for a moment and note that Artun et al (1990) found that substantial (>10 degrees)
proclination of lower incisors was not associated with greater subsequent relapse than a group treated
without proclination. However, these were severe Class 3 patients who, subsequent to lower incisor
proclination, had a backward mandibular sagittal split osteotomy; i.e. if you radically change the soft tissue
environment by surgical repositioning of the jaw, the usual soft tissue effects do not seem to apply.

An interesting suggestion is the one formally advocated by Selwyn-Barnett (1996) who points out that in
effect the lips cannot ‘know’ which incisor is touching them and that we can therefore procline the lower
incisor in class 2 division ii cases to touch the lower lip at the same A-P position as was occupied before
treatment by the extruded upper incisor. The stability of the results of such a philosophy has not been well
tested, but the resulting plan is often required in any case to achieve occlusal goals (Andrews’ keys 3 and
6) and is a useful way of structuring a plan to procline the lower incisors in such cases, as well as a
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sensible hypothesis about stability. However, Canut and Arias (1999) found that proclining lower incisors in
class 2 division ii cases lead to much more relapse of arch irregularity than when the arch length was not
increased. This is salutary evidence that a plausible hypothesis may be incorrect. We aim to retain with
particular care Class 2 division 2 cases in which we have substantially proclined the lower incisors and with
increasing emphasis on informed consent, prior information about the need for and importance of retention
is especially relevant in these cases.

Aesthetics and incisor position

Most proponents of a particular anteroposterior goal for the dentition have based their advocacy primarily
on the aesthetic advantages. There is, however, very little direct evidence concerning this question. An
opinion may be formed based on the fact that the Tweed analysis frequently retroclines lower incisors and
the Ricketts analysis frequently plans for labial movement of lower incisors, but what also matters
aesthetically in this respect is the anteroposterior position of the overlying lips and this is extremely
variable. Park and Burstone (1986) have shown in a very elegantly conceived study that the soft tissue
appearance of the lips in relation to a soft - tissue APo line varies enormously even when the Ricketts hard
tissue APo line goal is exactly achieved. Achievement of a particular lower incisor position will therefore
produce an enormous variety of profiles, although it is still probably true that for any given patient, some
lower incisor positions will produce a more aesthetic lip position than others. Even here, opinions vary as
to what is aesthetically desirable, treatment to Merrifield’s profile line tending to produce less prominent lips
than treatment to Ricketts’ E line for example.

Variability of soft tissue response

Quite separate from this question of variability in soft tissues for a given hard tissue position is the fact of
the variability of soft tissue response to tooth movement. This is also well documented. Staggers (1990),
for example, comparing premolar and second molar extractions, found definite differences in the A-P
changes in incisor position between the two groups, but no differences in the changes in soft-tissue facial
convexity or of the upper lip relationship to a soft-tissue APo line. Almost all studies show that the soft
tissues move much less than the underlying teeth. For example, Paquette, Beattie and Johnston (1992)
found an average 1.4 mm posterior movement of the upper lip when the upper incisors were retracted by
an average of 5.0 mm – an average ratio of 28%. Large tooth movements are therefore required on
average to produce clinically substantial soft tissue change, but the variability is huge. In this paper, the
range of upper lip anteroposterior change associated with upper incisor retraction was 10.0 mm! Pancherz
and Anehus-Pancherz (1993) reported that there was no correlation (r=0.02) between the hard and the soft
tissue changes brought about by treatment with the Herbst appliance. More recent papers have continued
to find poor correlation between incisor movement and change in the overlying lips. Kusnoto and Kusnoto
(2001) found a correlation coefficient of r=0.39 for the upper lip. In other words, the change in incisor
position accounted for r2 = 16% of the variation in lip change. The average ratio of movement was 1:4 for
lip: incisor change. A paper by Lai et al (2000) suffers from choices in cephalometric values, which greatly
lessen the potential usefulness of the results, but still reveals “a large variation in the soft tissue response
to dental movements”. The paper includes the result that two groups which differed in their change in
upper incisor inclination during treatment by an average of 20 degrees, differed in their change in upper lip
to E line distance by an average of only 0.5 mm.

Changes in antero-posterior incisor position clearly result in much smaller and highly variable changes in
the prominence of the overlying lips. Treatment to a hard-tissue target incisor position chosen almost
entirely for aesthetic reasons is therefore prone to a very wide range of possible aesthetic outcomes.

A suggested lower incisor target position

All orthodontists need to look at the available evidence and decide their general aims in relation to this
important target. As a starting point, the evidence relating to stability indicates that we should aim not to
change the antero-posterior position significantly during treatment unless there is a good reason. Most
orthodontic cases (as opposed to orthognathic surgical cases) can be treated without significantly altering
the labiolingual position of the lower incisors. Also, the aesthetic consequences of changing their position
are unpredictable and usually small. However, if this goal of aiming for little change in the initial antero-
posterior position is unwaveringly followed, there are several categories of patient where this would have
substantial disadvantages.
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• in some cases, the aesthetic concerns of lip prominence or inclination are sufficiently marked
that they outweigh considerations of stability. For example, in a well-aligned class 1
bimaxillary proclination case, excessive lip and tooth prominence is probably the only
potential indication for treatment. Equally, some class 2 cases have a very obtuse nasolabial
angle. This can be a factor to tip the treatment plan towards surgery. Where surgery is not
an option, this factor may sometimes lead to a decision to plan for significant lower incisor
proclination to maintain upper lip support whilst reducing the overjet.
• some cases (e.g. some class 2 division ii patients) are impossible to treat to our chosen
occlusal goals without substantial lower incisor proclination.
• correction of class 3 cases without orthognathic surgery frequently requires significant lower
incisor retroclination.
• many cases with mild lower arch crowding are very demanding on the wear of class 2
traction if lower arch extractions are prescribed and unwanted incisor retroclination is to be
avoided. It is better to move the lower incisors labially to the modest extent required.
• from a purely pragmatic viewpoint, some cases become extremely anchorage demanding if
the lower incisors are not moved labially. This point is less frequently mentioned than others
such as considerations of profile, but can undoubtedly be a powerful if unstated motive.

Aesthetics versus stability ?

Small antero-posterior changes in lower incisor position are of little consequence for either appearance or
stability. The evidence is that the larger the change, the more these two factors will - on average - conflict.
Choosing a position that is less likely to be stable means more emphasis on ‘permanent’ retention and this
is the source of a philosophical dilemma. The work of Little and others quoted above has shown that
although larger lower incisor changes in position are less stable, lower incisor alignment tends to
deteriorate after retention whether or not the lower incisor position has been maintained. In the light of this,
two tenable viewpoints have emerged.

Since tooth alignment tends to deteriorate even if we put the teeth where stability is most probable:

• all cases should have indefinite retention and if this is the case, then why should the
orthodontist be concerned with minimising spontaneous relapse when all case are to be
retained forever anyway?

Or alternatively

• for one reason or another few young patients wear retainers for the rest of their life and it is
therefore best practice to try to leave the lower incisors in a position that minimises the
probability of relapse when retention is discontinued.

These two approaches are both entirely tenable. At present we favour the second viewpoint as a starting
point, with some exceptions for the aesthetic, occlusal and anchorage reasons listed above. A
complicating factor for those looking for certainties in life is that all these exceptions are relative and thus
open to weighting which varies even between clinicians who would subscribe to the same choice of the two
opposing viewpoints.

The question of a suitable goal for lower incisor position is inextricably entwined with extraction philosophy
and the merits and disadvantages of extractions per se should now be examined - a subject of recently
revived controversy.

Extractions vs. non- extraction treatment

This ancient debate about the possible benefits and disadvantages of extractions is almost as old as
orthodontics itself, but has resurfaced recently with all the heat and fury that apparently occurred at the
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time of Angle vs. Case (see the articles by Bernstein 1992). In the USA, the debate has on occasion
become markedly acrimonious. It is clearly important to look as objectively as possible at the evidence
concerning the issues relating to extractions.

Reasons for elective extractions in orthodontics

Before examining possible disadvantages of extractions, it is worth reminding ourselves of the reasons for
wanting to remove teeth electively.

• relief of crowding
space is provided for crowded teeth without expanding the arches laterally or anteriorly (or in
the upper arch, without transferring the crowding to a more distal part of the arch).
• correction of incisor relationship
o overjet reduction
o lower incisor retroclination to correct a class 3 relationship
o providing the space required to move upper labial segment contact points distally as
retroclined upper teeth are torqued to a correct inclination in the correction of a class 2
division ii relationship
o correction of bimaxillary proclination
• provision of anchorage
in addition to providing the space for tooth movement, extractions frequently provide
additional space which is harnessed to provide intraoral anchorage. Mesial movement of
anchor teeth in response to reciprocal forces is therefore possible without the arch having to
be expanded anteriorly to accomplish the desired occlusion. Without extractions, no intraoral
anchorage is available for distal movement of teeth (except in naturally spaced dentitions)
unless incisors are moved labially in one arch or the other. In non-extraction treatment
(discounting unpredictable favourable growth), anchorage must be gained extra-orally or
from implants or alternatively, incisors must move labially or buccal teeth must expand

Proposed disadvantages of extractions

Several disadvantages have been proposed:

• mandibular dysfunction.
• a less attractive dental and facial appearance.
• longer, more difficult treatment
• pain, anxiety and other possible adverse effects of the actual extraction procedure.

The third and fourth reasons may be significant factors in the decision process.

Extractions and mandibular dysfunction

It has been suggested that extractions may cause mandibular dysfunction by two mechanisms.

• the effect on condylar position within the fossa

• loss of vertical face height.

Regarding condylar position, such authors as Witzig and Spahl (1987) and Bowbeer (1987) have proposed
that extractions cause “over-retraction” of the upper incisors and that this leads to the condyles being
forced posteriorly and hence the articular disc becomes anteriorly placed and hence mandibular
dysfunction. The work previously quoted in the chapter Occlusal Treatment Goals demonstrates the
paucity of evidence of an association between condylar position and mandibular dysfunction and indeed
the inability of orthodontics or restorative dentistry to alter it permanently. With specific reference to
extractions, Gianelly (1991a and 1991b) has found no difference in condylar position between those treated
with the extraction of four premolars and those receiving no orthodontic treatment. This has been
supported by work by Kundinger et al (1991). Luecke and Johnston (1992) found that the temporary effect
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of orthodontic treatment on condylar position was highly correlated with the mesial movement of buccal
segments but not at all with the retraction of incisors. Major et al (1997) used tomography to show that
condylar position was unchanged by treatment in both non-extraction and extraction groups. With regard
to the view held, for example, by Bowbeer (1987) that extraction of premolars causes a loss of vertical
dimension and that this causes mandibular dysfunction, Staggers (1990) was unable to find any such effect
in a study of premolar and second molar extractions. Kocadereli (1999) also found no difference in change
in vertical facial dimensions between 40 cases treated non-extraction and 40 cases treated with first
premolar extractions.

It remains possible that extractions predispose to mandibular dysfunction by some other unknown
mechanism. However, studies by such workers as Kremenak et al (1992) have found no differences
between groups treated with loss of upper premolars, four premolars and non-extraction. Beattie et al
(1994) also found no difference in the CMI values for non-extraction cases and extraction cases. In this
clever study, the principle of equipoise was used to get two groups matched for all the variables which
discriminant analysis had shown to be able to account for the decision to extract or not. In other words, a
rare and necessary feat was achieved - to compare the results of extraction versus non-extraction in
groups of comparable cases.

There appears to be very little evidence to support either of the proposed mechanisms for causation of
mandibular dysfunction by extractions or indeed to support any other unknown mechanism. There is
therefore no reason to avoid extractions because of concerns about mandibular dysfunction.

Extractions and facial aesthetics

Orthodontic treatment involving extraction has also been accused of producing unpleasantly retrusive lips
relative to the nose and chin. Studies have certainly shown that it is possible to achieve a degree of long
term retroclination of the lower incisors and that this will be associated with the lips being more posterior
than would have been the case if the incisors were more procumbent. The variability of soft tissue (lip)
position for a given underlying incisor position and the variability of soft tissue response to anteroposterior
movement have already been discussed, but it remains true that for a given individual, more posterior
incisors means more posterior lips to an unpredictable extent. However, studies comparing the soft tissue
changes in patients with differing extraction patterns inevitably encounter the fact that the groups are very
unlikely to be balanced in terms of requirements for space and anchorage. For example, Staggers (1990),
comparing first premolar and second molar extractions, found that the anteroposterior changes in lower
incisor position were only minutely different and the soft tissue changes were very variable, but on average,
identical. This would not be at all surprising if the second molar extraction group had much less initial
crowding. This study at least shows that it is nonsensical to generalise about the effects of extractions on
lower incisor position regardless of other features of the malocclusion and treatment.

Similarly, the studies by Luppanapornlap et al (1993) and by James (1998), both demonstrated that
patients treated with extractions had on average slightly more prominent lips at the end of treatment than
those treated on a non-extraction basis. This reflected the fact that initial lip prominence was a significant
factor in the extraction/non-extraction decision of the orthodontists planning that group of patients. A recent
study by Zierhut et al (2000) again showed the small extra lip retraction with extractions (1.7 mm for the
lower lip and 1.0 mm for the upper lip) when compared with non-extraction cases, but since extractions had
been chosen in cases with slightly more prominent lips, the final average soft tissue profile was identical in
both groups. Finally, the study by Shearn and Woods (2000) was notable for showing the wide variety of
antero-posterior changes in lower incisor position, which result for all combinations of premolar extractions.
This is simply a reflection of all the other variables in the treatment - notably the amount of crowding, of
class 2 elastics, of headgear and of differential growth. An opinion that extractions or non-extraction are
“good” or “bad” for the profile is clearly simplistic and uninformed.

Lay opinion
A good study by Bishara and Jakobsen (1997) involved assessment by lay people of profile changes in
class 2 division i malocclusions treated with and without extractions. Lay judges:

• preferred the profile of normals to the pre-treatment profile of Class 2 division i patients
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• immediately after treatment, preferred the changes in profile in the extraction group to the
changes in the non-extraction group
• two years after treatment, showed no preference for the profiles of either treatment group or
for the untreated normal group
• considered the changes with treatment to be very favourable in both treatment groups.

This suggests that orthodontic treatment with good planning and execution can produce changes in profile
which are viewed favourably by the lay public whether or not extractions are involved.

The remaining relevant questions about extractions and facial aesthetics

These would seem to be as follows:

• how big are the average differences in soft tissue appearance if the same case is treated
with extractions or non-extraction? This will presumably be related to the extent of the space
requirements – crowding and overjet.
• do any differences in soft tissue appearance caused by extraction affect patients' opinions of
their appearance?
• if there are appearance advantages for a particular extraction pattern, are these offset by
other disadvantages? e.g. if non-extraction produces a facial appearance which the patient
prefers, is this offset by increased instability of the result? Or, e.g. if extraction produces an
appearance which the patient prefers, is this offset by treatment being longer and more
difficult?

Differences in soft tissue appearance if the same case is treated extraction or non-
extraction
Of course, the answers to these questions will also be different for different types of malocclusion. Not
much evidence, as opposed to opinion, exists on any
of the questions, but the study by Paquette et al
(1992) referred to above, gave some extremely useful
information for one type of malocclusion. The
equivalent groups of cases assembled by the
equipoise analysis as being equally susceptible to
extraction or non-extraction, were unsurprisingly, mild
to moderate class 2 division i malocclusions with mild
lower arch crowding. The cases averaged 14.5 years
post-retention and were recalled and compared
aesthetically, for mandibular dysfunction and for
stability.

Cephalometrics of the long term results revealed that

the extraction group had lower incisors averaging 2
mm more posterior than the non-extraction group and
the lower lip was 1.2 mm further behind E line in the
extraction group. However, these measurable and
statistically significant differences produced no
detectable aesthetic or stability effects. Regarding
aesthetics, various assessments of the patients'
opinion of the aesthetic changes in their silhouettes
and facial photographs both before and after
treatment revealed no difference between the groups.
Regarding stability, the Little index in the lower labial
Figure 3.2: The average long term differences in tooth
and soft tissue sagittal positions in two groups of equivalent cases
segment at recall was 2.9 mm in the extraction group
treated by premolar extractions or non-extraction. Redrawn from a and 3.4 mm in the non-extraction group. This
study by Paquette et al (1992) difference was again not significant, although the
overall reduction in lower labial irregularity was
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slightly greater in the extraction group (by 1.9 mm.), which happened to be slightly more crowded initially
and relapsed fractionally less.

It would seem that in such mildly crowded cases, if they are treated using non-extraction mechanics which
only produce mild labial movement of the lower incisors, (average 0.4 mm in this group), it does not matter
significantly whether the cases are treated with or without extractions from the viewpoint of aesthetics or
stability. If it is felt that treatment will be quicker, easier or more pleasant if carried out on a non-extraction
basis, then this would be the sensible approach in this type of case. The study did not investigate these
latter aspects, but it seems reasonable to assume for now that if all things are genuinely equal for a given
type of case, we should not extract.

An interesting prospective study by Heiser et al (2004), compared two groups with equivalent starting
irregularity index (averaging 5.1 and 5.8) treated with and without premolar extractions. It is very probable
that the non-extraction group had some labial movement of the lower incisors relative to the extraction
group. They measured areas bounded by different parts of the dental arch. The increase in the area
bounded by the lower labial segment relapsed more in the non-extraction group, but interestingly, the
relapse in Irregularity index was the same in both groups. The connection between change in lower incisor
proclination and irregularity index is clearly not a close one. For relatively mild crowding, treated in the
permanent dentition, extractions possibly confer no significant additional stability of alignment.

In his long-term studies of dental irregularity, Little (1990) has identified “lower arch development in the
mixed dentition” (i.e. expansion and proclination of the labial segment) as the only treatment regimen to
show significantly worse results than others in this respect. Little (2002), again referred to this work in his
paper contributing to the section on early treatment which followed the American Association meeting on
that subject. The core of his findings were that whilst you can hold and use the Leeway space without any
detriment to stability, lateral and anterior expansion of the arches at an early age caused a degree of
relapse which was “significant and alarming” and this was for cases which only had to have mild
proclination to be included in the “expansion” group. Conversely, a paper by Ferris, Alexander, Boley and
Buschang (2005), showed that patients with mild crowding but significant irregularity, when treated in the
late mixed dentition with RME, arch expansion, interdental stripping and without extractions, had very
acceptable stability more than 4 years out of retention. There was no availability of cephalometric data on
incisor labio-lingual movement, but the arch width measurements showed that a substantial percentage of
premolar expansion was stable in this age group. The effect of extraction choices on lateral stability and
smile aesthetics is considered below and in the following chapter on Facial Appearance, the Smile and
Tooth Aesthetics.

Extractions and smile width

So far, this section has dealt with the antero-posterior effects of extractions. Interestingly, the clever study
by Spyropoulos et al. (2001) that used computerised modification of photographs, concluded that factors
other than profile outline may be more important in facial aesthetics for lay people and it is orthodontists
who pay particular attention to the profile. Orthodontic treatment involving extractions has been accused in
recent years of causing larger dark intraoral spaces lateral to the buccal segments - a “dark buccal
corridor”. However, the study by Johnson and Smith (1995) found no evidence of this and also no
evidence that extractions produced less attractive smiles in the opinions of lay judges.

Two more recent studies by Gianelly have looked at the relationship between extractions and width of
dentition. In the first, (Gianelly 2003a), he compared a non-extraction group with an extraction of four first
premolars group. The principal finding was that post-treatment, canine, premolar and widest molar widths
were essentially the same in the two groups. The second similar study (Gianelly 2003b) is more
interesting. The first point of note is that he added a measurement at constant arch depth from the upper
central incisors and this depth corresponded to the average depth of the molar-premolar contact in a group
of non-extraction patients. This is a sound idea, since measurement at a constant arch depth overcomes
the problem that non-extraction may well involve distal movement and therefore molar expansion whilst
conversely there is frequently molar constriction in extraction case just because the molars move mesially
into a narrower part of the arch. The results for this measurement at constant arch depth showed that the
extraction group was slightly wider after treatment than were the non-extraction group. This is a good
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measurement for future studies. The second part of the study was similar to that by Johnson and Smith.
Fifty lay judges were asked to rate close up photos of 12 extraction and 12 non-extraction smiles. There
were no differences in the aesthetic scores between the groups. Interestingly, the lay judges again
seemed unaware of ‘dark buccal corridors’ as an aesthetic factor in smiles, since only one of them
mentioned it at all. Also there was no difference in the number of teeth displayed in the two groups whilst
smiling.

These two studies are similar in many respects to many studies comparing profiles in extraction and non-
extraction groups. They are useful in that they look at (and indeed refute) the idea that extraction results in
a narrow arch at the dental smile width, but this leaves unanswered what would result if the same cases
were treated with the two regimens – especially if the space requirements were substantial. The Gianelly
studies naturally involved cases where clinicians had picked horses for courses when choosing to treat
extraction or non-extraction. The cases were not matched.

The study that is needed

Some clinicians treat virtually everything non-extraction. Matched cases are required with large space
requirements which are treated differently. Using the discriminant analysis methods so pertinently applied
by Lysle Johnson, such a study must be possible with the cooperation of clinicians of differing philosophies.
The results would still leave the question of the stability of expansion as a factor in treatment planning, but
would more thoroughly examine the aesthetics of expansion.

Overall assessment of smile aesthetics

Aside from the specific issue of extractions, it is helpful here to refer to two papers by Sarver and Ackerman
(2003a and 2003b). These consider all dimensions of smile aesthetics and advocate extracted frames
from video to select the best image for assessment. Several aspects of their advocated measurements
and assessments are useful food for thought on this subject which can generate considerable heat e.g. the
letter by Spahl in response to the article by Gianelly (2003a). Two studies using digitally altered buccal
corridor spaces are well worth a look. A paper by Moore et al (2005), supported the view that the
appearance of small buccal corridors is preferred by lay judges, whilst the similar study by Roden-Johnson
et al (2005), showed no such effect. Details of study design, such as the extent of the digital alteration or
the definition of buccal corridor, may well be important in these investigations. The following chapter on
Facial Appearance, the Smile and Tooth Aesthetics gives a thorough overview of this topic.

Planning extractions
In the light of the previous scrutiny of the current evidence, we can now produce suggested guidelines for
the practical implementation of extraction planning. This section is a series of rules of thumb with
supporting explanation and references. It is hoped that this provides a straightforward sequence of
evidence-based thoughts which will produce a sensible extraction plan in the large majority of case where
there is a full complement of healthy teeth. The two articles by Kirschen et al (2000) describing the Royal
London space planning method are recommended reading. The advice in this section will give the same
plan as the formal Royal London method in almost all cases where the same lower incisor position and
treatment mechanics are planned.

Plan the lower arch first

This adage still seems very sensible in the light
Category Millimetres of crowding Extraction pattern of the evidence reviewed above. Almost always,
Mild 1 to 4 mm Non-extraction or if we extract in the lower arch, there is some
second premolars
residual space to close. If the lower incisors are
Moderate 5 to 8 mm First premolars or
second premolars
not to be retroclined (and this is rarely desired),
then class 2 traction is required.
Severe 9+ mm First premolars

Table 3.1: Common extraction patterns related to category of

crowding. Other factors modify this starting point.
Assessing the lower arch crowding
The amount of crowding is a sufficiently strong
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factor to narrow the choice by itself to one of two lower arch extraction patterns in many cases.

The recommendations in Table 3.1 imply a differential anchorage effect between extraction of first or
second premolars. This differential has long been assumed from the differential force theory, but is
supported by a recent paper by Saelens and de Smit (1998) where the extraction of first premolars
successfully accommodated twice the crowding than did the extraction of second premolars. The average
lower incisor antero-posterior change was the same in both groups (0 mm) and the molars moved mesially
1 mm more in the second premolar extraction group. This convincing evidence is supported by the paper
by Ong and Woods (2001) which clearly showed more anchorage is provided in the upper arch by
extraction of 4s than by extraction of 5s. Creekmore (1997), reviewing this subject concludes that as a rule
of thumb, extraction of first premolars provides approximately 66% of the space for aligning/retracting the
anterior teeth, whereas extraction of second premolars provides approximately half of the space.

Other factors will significantly influence the choice of extractions within each category.

• antero-posterior incisor position

• canine expansion
• canine angulation
• curve of Spee

The effect on available space of antero-posterior expansion/retraction

The traditional rule of thumb is that 1 mm of labial movement will provide sufficient space for 2 mm of
crowding (1mm on each side of the arch). This rule of thumb assumes a rectangular arch form. In fact,
with a much more realistic parabolic archform, the situation is more complicated and in general the labial
movement will need to be greater than 1 mm to produce 2 mm of space. The paper by Steyn et al (1996)
demonstrates this and interestingly, also calculates the effect of different arch depths and widths on the
anterior movement of incisors required to accommodate a given amount of crowding. In general, the wider
the intercanine distance and the shallower the arch depth from the canines to the mid-incisor point, the
greater the A-P expansion required to accommodate a given amount of crowding (or conversely the greater
the A-P retraction of incisors for a given amount of interdental stripping) and in cases presenting a specific
dilemma, inspection of the table in the paper by Steyn is recommended

In a given instance, the labial movement of lower incisors in a non-extraction case is frequently greater
than that required to accommodate the crowded teeth. This reflects the additional use of class 2 traction
and the degree of control of lower incisor inclination with occlusal plane levelling. For example, in non-
extraction cases Saelens and De Smit (1998) found an average 5 mm of labial movement of lower incisors
with average initial crowding of only 4 mm in both arches.

The effect on available space of lateral expansion

Lateral expansion has been found to have less effect on arch perimeter than A-P expansion. An
interesting paper by Noroozi et al (2002) from Tehran, demonstrates the ability of an algorithm based on
two measurements of arch width and two of arch length to predict the arch perimeter increase which will
result for any given A-P or lateral expansion. These authors again find that A-P expansion is much more
effective than lateral expansion in providing space. Their formula predicts approximately 1mm of arch
length for 1mm of incisor labial movement. This is half of the ‘rule of thumb’. In the lateral dimension, each
mm of canine expansion gives 0.6 mm of space and each mm of second molar expansion gives 0.3 mm.

The amount of curve of Spee

The historical rule of thumb for this factor was 1 mm of space required for every 1 mm depth of curve of
Spee. This has been shown to be an excessive calculation of space required. Germane and Staggers
(1992) found a non-linear relationship and a less than one to one ratio for curves shallower than 9 mm. A
more recent study by Braun et al (1996) found an even smaller effect - namely that a very deep curve of 9
mm only requires 2 mm of additional space. The labial flaring of lower incisors associated with non-
extraction levelling of curves of Spee is therefore mainly due to choices in the biomechanics employed
rather than to the space requirements. This will be discussed further in the chapter on Managing Overbites
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and is also referred to in the section on bracket prescriptions in the chapter on The Development of
Preadjusted Appliance Systems.

The factors which influence the choice of antero-posterior lower incisor position and any change in arch
width will be those of stability, aesthetics and ease of treatment discussed earlier.

If the lower arch is non extraction:-

Then non-extraction is our treatment of choice in the upper arch. If the case is suitable for functional
appliance treatment then this is our preferred option if class 2 correction is required. If the upper second
molars have erupted, the upper third molars are present and of good size and at least half a unit of distal
movement is proposed, then the extraction of upper second molars can be considered. Waters (2001) has
reported that this achieved 1.2 mm additional distal movement of the upper first molar and 5 degrees less
incisor proclination, but this should be weighed against the long -term disadvantage of having a smaller
more conically rooted third molar in place of a second molar. We rarely extract upper or lower second
molars.

Although non-extraction is our treatment of choice if the lower arch is non-extraction, extraction of upper
first premolars is much less demanding on anchorage and the occlusal disadvantages of a class 2 molar
relationship are slight (see Andrews 1989: Straight Wire: The Concept And Appliance pages 182-187). If
the initial molar relationship is more than half a unit class 2 and the case is not ideal for functional
appliances, we would usually advocate extraction of upper first premolars. This does carry an increased
chance of small residual spaces in the extraction sites. This is due partly to the difference in mesiodistal
width between two premolars and one first molar and partly to the second premolars being teeth that are
more frequently disproportionately small. This was discussed in the chapter on Occlusal Treatment Goals.
Such occlusal imperfections may be considered much more acceptable than the consequences of
insufficient anchorage to correct a class 2 relationship.

If lower premolars are extracted:-

Then upper premolars are almost always extracted. If the upper canines are at an ideal angulation or more
distally angulated and must move distally by half a unit or more, then extraction of upper first premolars is
recommended.

All these suggested guidelines for extractions with pre-adjusted edgewise appliances assume a full
complement of healthy, normal size teeth.

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A cephalometric comparison of maxillary second molar extraction and non-extraction treatment in patients with
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Useful related references not referred to in this chapter

Proffitt WR (1994)
Forty-year review of extraction frequencies at a University orthodontic department
Angle Orthodontist 64: 407-13
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