A Longitudinal Evaluation of Extraction

Versus Nonextraction Treatment With

Special Reference to the Posttreatment
Irregularity of the Lower Incisors
P.. Emile Rossouw, 1 C. Brian Preston, 2 a n d Carl L o m b a r d 3

A tendency exists in contemporary orthodontics to pursue a completely

nonextraction philosophy. Moreover, it has been shown that the extraction
versus nonextraction debate is still with us. Controversy exists as to which
treatment decision will eventually lead to orthodontic stability. It is thus
imperative to conduct investigations on long-term changes of the dentition
in both treatment regimens. The present study serves as an example of such
a longitudinal study. A random sample, inclusive of both extraction and
nonextraction treatments, was examined with respect to long-term stability
and an assessment was made as to whether one treatment option favors
success over the other. It was concluded that the correct initial treatment
choice will not only lead to correction of the malocclusion, but will also
ensure clinically acceptable stability with no significant differences between
extraction and nonextraction treatments. (Semin Orthod 1999;5:160-170.)
Copyright © 1999 by W.B. Saunders Company

t is m u c h easier to extract teeth than to
I determine with certainty whether it is abso-
lutely necessary to do so. The extraction of a
tooth requires n o t h i n g more on the part of the
practitioner than some skill in the use of the
instruments that are usually used in this opera-
tion, whereas the knowledge necessary to appre-
ciate the long-term consequences of dental ex-
tractions can only be acquired by time and
study. 1 Extraction of teeth as an aid in the
treatment of malocclusion is one of the oldest
and most controversial subjects in the history of
orthodontics. During the early 1900s the contro-
versy reached its peak with Edward H. Angle and
Calvin S. Case representing opposing views in
this matter. 2
Angle's nonextraction influence dominated
the discipline of orthodontics for many years. He
From the University of Toronto, Toronto, ~ State University of N~w
York at Buffalo, N Y 2 and MR(L Tygerberg, RSA 3
Address correspondence to P. Emile Rossouw, BSe, BChD, BChD
(Hons), MChD, Phi-), Faculty of Dentistry, 124 Edward St, Toronto,
Ontario, M5G 1G6, Canada.
Copyright © 1999 by W.B. Saunders Company
1073-8746/99/0503-0005510. 00/0
maintained that the loss of premolars arrested
facial development and expression and was far
more damaging to the patient's future than were
crowded anterior teeth. According to Angle,
extraction procedures never overcame faulty
muscular function 3 and, accordingly, orthodon-
tic treatment should set out to r e m o v e t h e causes
of malocclusion while retaining a full compli-
m e n t of teeth. 4 With the development of gna-
thostatic evaluation of dental occlusions, as well
as the simultaneous introduction of cephalomet-
rics by Broadbent 5 and Hofrath, 6 the limitations
of a d o m i n a n t nonextraction philosophy could
be assessed.
The extraction controversy gained momen-
tum in the 1920s when Case p r o m o t e d extrac-
tions in orthodontic treatment. 7 Many others
also resisted Angle's d e m a n d that the teeth
should be kept in place despite the type of
malocclusion being treated, sq° A large percent-
age of malocclusions, which orthodontists are
called u p o n to treat, have deficient a n d / o r
d e f o r m e d apical bases, n Extractions thus may
b e c o m e necessary in order to create a harmoni-
ous environment. Begg 12 supported extractions

160 Seminars in Orlhodontics; Vol 5, No 3 (September), 1999: pp 160-170

 Extraction Versus Nonextraction Treatment
in orthodontic procedures as a result of his
studies of stone-age man's dentition where good
alignment of teeth was attributed to interproxi-
real attrition as a result of coarse diets. Subse-
quently, he advocated extractions as a means of
compensating for the lack of attrition in most
m o d e r n dentitions.
Tweed, as one of Angle's most ardent support-
ers, was so discouraged by postretention relapse
that he seriously considered giving up his profes-
sion as an orthodontist. He examined 70% of the
patients whom he had treated during 6.5 years of
orthodontic practice, during which he followed
Angle's philosophy, which d e m a n d e d a full
c o m p l e m e n t of teeth. To his amazement, he
f o u n d that only 20% of the patients whom he
reviewed still met his original orthodontic objec-
tives:
1. A stable end result-teeth that remain in their
corrected positions.
2. Healthy investing tissues to insure longevity of
the denture.
3. A dental apparatus which works efficiently.
4. The best facial aesthetics.
A study that included 100 extraction and 100
nonextraction subjects, was investigated 25 years
postretention.14 Although not based on scientific
facts, Tweed concluded that the extraction cases
were more stable than were the nonextraction
cases. Glenn, Sinclair, and Alexander 15 studied
28 nonextraction cases, who were an average of 8
years out of retention. In these patients, who
were treated by the same orthodontist, they
f o u n d that slight incisor irregularity occurred
postretention. Relapse patterns were similar to,
but more severe than, those seen in a study
conducted in an untreated normal population. 16
The changes in the normal population were only
one half as severe as those observed in studies
carried out by Little et al.17,18
The question thus arises as to what effect the
orthodontic technique or appliance manage-
ment may have on the long-term dental changes.
According to Litde et al, 17,1s when lower inci-
sors, measured to the Point A-Pogonian (APo)
line, were proclined an average of 1.4 m m
during treatment, they tended to remain stable
postretention. Sandusky 19reported on the postre-
tention stability of 83 extraction cases treated by
Tweed and Tweed foundation members. Using
Little's Irregularity Index 2° to grade the results,
161
Sandusky ~9 f o u n d less than 10% relapse of the
lower incisors. Similar results showing that lower
incisors maintained better alignment after orth-
odontic treatment were reported by Davis m and
Kuftinec.22 In a sample consisting of 45 nonextrac-
tion and 27 extraction cases Uhde, Sadowsky,
and BeGole 23 showed a greater degree of crowd-
ing at the beginning of treatment, and less
relapse 20 years postretention in the extraction
group than in the nonextraction group of pa-
tients.
The presence of mandibular incisor crowding
indicates that there is a space shortage some-
where in the dental arches.
The incisor position 24-27and facial profile, 2s in
combination with a tooth-arch size analysis, pro-
vide clues which can help to make a decision
whether an extraction or nonextraction treat-
m e n t regime must be followed. Mandibular inci-
sors should, as is f o u n d in normal individuals,
always be positioned upright over the medullary
bone of the jaw. 8 Relapse of orthodontically
treated dentitions may be influenced by apical
base differences, the subject's age, the time of
retention, incisor positions relative to basal bone,
posttreatment growth, third molar development,
periodontal fibers, habits, occlusal functioning,
Bolton discrepancies, continued decrease in arch
length and other unknown f a c t o r s . 17 Richard-
s o n 29,3° summarized a n u m b e r of possible causes
of mandibular arch crowding.
Following a nonextraction philosophy in the
belief that a particular orthodontic appliance
will enhance bone growth could lead to a great
deal of disappointment. It is probably impossible
to induce meaningful growth in tooth-bearing
bones by means of orthodontic appliances, sl
Brodie 3"2 also showed that once the growth pat-
tern of the facial bones is established, whether
normal or abnormal, it is virtually constant and
resistant to change. Natural expansion does,
however, occur as a result of normal growth and
development. ~3 It would he incorrect to assume
that those appliances used during this growth
period were the cause of the expansion. The area
of the alveolar arch correlates closely with the
area of the dental arch. s4 A cephalometric study
that evaluated relapse in Class II Division 1
subjects who where treated without extraction of
teeth, with either the Andresen activator or the
Bionator, showed considerable individual varia-
tion in relapse of overjet. 35 Using the results of a
16t Rossouw, Preston, and Lombard
n u m b e r of cephalometric studies dealing with
the treatment effects of functional appliances on
Class I1 division 1 malocclusions, it was con-
cluded that overjet reduction occurred predomi-
nantly as a result of dentoalveolar changes. 36
Dentoalveolar changes also appeared to be largely
responsible for overjet relapse especially when
incisors were proclined during treatment. 3739
Anteroposterior a n d / o r lateral increase in
the mandibular arch form usually fails with the
dental arch typically returning to the pretreat-
m e n t size and shape. 4° Malocclusions treated by
means of rapid maxillary expansion, however,
have been shown to remain stable 8 years post-
treatment. 4~ Haas maintained that his success
can be ascribed to a combination of his m e t h o d
of treatment (rapid maxillary expansion) and to
the duration of the retention which he uses.
Subjects treated without extraction by means of
Bimler appliances showed a greater degree of
u p p e r lip flattening as a result of a stretching of
the lips. This stretching apparently results from
an increase which occurs in anterior facial height.
Patients in whom extractions were p e r f o r m e d
seemed to maintain more aesthetic lip morphol-
ogy.42 Conlin 43 recalled 1,000 subjects and evalu-
ated their long-term dental stability and facial
aesthetics. He f o u n d that there was no real need
for extraction cases to appear fiat or for nonex-
traction cases to appear full.
One of the greatest challenges in o r t h o d o n -
tics is the need to make a sound diagnosis. No
c o o k b o o k recipe is available with respect to
extraction or nonextraction treatment. Various
strategies are used to aid orthodontists in their
extraction decisions including the use of visual
treatment objectives. 44,45 Clinical experience
gradually allows each orthodontist to develop
their own philosophy. 46
The frequency of extractions varies greatly
a m o n g orthodontists. A study in the northwest-
ern US revealed that the average prevalence is
about 42.1%.47 A n o t h e r study f o u n d the range to
vary between 5% and 87% with the average
being 39%. 48 Ethnic and socioeconomic differ-
ences will obviously influence the prevalence of
the extractions p e r f o r m e d by orthodontists.Japa-
nese and Chinese orthodontists treat many bi-
maxillary protrusions employing the extraction
of teeth, whereas g o v e r n m e n t clinics in Eastern
Europe favor nonextraction treatment. The Na-
tional Health scheme in England also appears to
have tilted the scale in favor of extractions in
orthodontics. 47 Extraction, as an only option,
regularly complicates a treatment regime. Prob-
lems, which dictate one or other form of extrac-
tion, which is not within the control of the
orthodontist, include: caries, periodontitis, end-
odontic problems, or even some developmental
defect. Extraction treatment on average was
f o u n d to require more treatment time to com-
plete than did nonextraction treatment. 49
The ultimate decision as to whether extrac-
tions should be performed, as part of the orth-
odontic treatment, may d e p e n d on how well the
patient cooperates. Anchorage control plays an
important part in allowing the clinician to achieve
the goals planned for. The conventional Begg
technique uses differential anchorage 5° and not
extra-oral traction to preserve anchorage when
retracting the anterior segment of teeth. 51 Wil-
liams and Hosila 51 noted additional advantages
to p e r f o r m i n g extractions. Extractions tended to
reduce the mandibular plane angle (FMA) be-
tween 1.2 ° to 1.8 ° during treatment, and the
chances of the wisdom teeth erupting improved
from 52.5% (first premolar extractions) to 90%
(first molars extractions). The latter observation
of third molar eruption, however, cannot be
taken for granted as it was shown that the
impaction of third molars was not necessarily
avoided by extracting premolar teeth. 52,53 Molar
extraction, however, will in most instances elimi-
nate third molar impaction. 54 Late lower arch
crowding may, on occasion, be prevented by
relieving the eruptive pressure from third molars
by extracting the lower second molar teeth. 55
In orthodontics a variety of teeth may be
extracted. These include mandibular incisors, 56,57
maxillary canines, 58 premolars, 59-65 first mo-
lars, 66,67second molars 55,68and third molars. 44,69,70
Lower incisor crowding, although it sometimes
occurs many years after successful orthodontic
treatment, signifies failure in orthodontics. The
extraction of four premolar teeth has been
r e c o m m e n d e d to limit incisor crowding after
orthodontic treatment. 71,72 Proffit 79 believes that
an additional benefit o f extraction therapy lies in
the better lip contours which are usually ob-
tained. There is no complete agreement with
respect to the latter observations. It has been
reported that irrespective of whether individuals
were treated with or without extractions, relapse
of overbite, 73 as well as relapse of lower incisor
 Extraction Versus Nonextraction Treatment
alignment, still occurs after the removal of the
a p p l i a n c e s J 7 Only a b o u t 30% of occlusions
treated with first p r e m o l a r extraction therapy
retained g o o d anterior m a n d i b u l a r alignment
while two thirds of the sample relapsed. ~7 In
c o m p a r i n g the results of a sample showing mini-
mal incisor relapse 19 with a sample showing
about two thirds relapse, a7 it was concluded that
the orthodontic technique used plays an impor-
tant role in achieving stability of the posttreat-
m e n t orthodontic result. 74
In an a t t e m p t to search for associations be-
tween long-term skeletal and dental change, a
cephalometric appraisal was p e r f o r m e d on first-
premolar-extraction subjects. 75 T h e posttreat-
m e n t and postretention incisor positions as well
as a m o u n t or direction of facial growth, were
f o u n d to be p o o r predictors of long-term man-
dibular incisor irregularity. O t h e r studies also
failed to d e m o n s t r a t e any correlation between
p r e t r e a t m e n t and p o s t t r e a t m e n t lower incisor
alignment in first, 17 and second p r e m o l a r extrac-
tions. 76 Statistically significant differences in their
cephalometric m e a s u r e m e n t s existed between
minimally, and moderately to severe crowding
groups in the postretention period of subjects
treated with second p r e m o l a r extractions. 76 Non-
extraction t r e a t m e n t regimes have also provided
information with respect to postorthodontic sta-
bility. 15,77,7s T h e lesser degree of initial crowding
in the nonextraction groups tend to bias such
studies and a direct comparison of extraction,
and nonextraction samples must therefore be
m a d e with c a u t i o n . 76
Teeth that are m o v e d together orthodonti-
cally following extraction of an adjacent tooth do
not move t h r o u g h the gingival tissue, but a p p e a r
to push the gingivae in front of t h e m into a fold
of epithelial and connective tissue. This excess
tissue can result in the o p e n i n g of the extraction
space, which constitutes a c o m m o n f o r m of
relapse of orthodontically treated occlusions. By
surgically removing this tissue, relapse could be
alleviated. 79 Enlow 8° defined relapse as "a histo-
genetic a n d m o r p h o g e n i c response to some
anatomical and functional violation of an exist-
ing state of anatomic and functional balance."
Relapse is usually t h o u g h t of as a " r e b o u n d "
m o v e m e n t in which teeth recoil back somewhere
close to their original positions once the reten-
tive forces are removed. Enlow does not accept
the idea that the relapse process is merely a
163
passive mechanical recoil reaction of the peri-
odontal m e m b r a n e to stresses placed on its
fibers. H e stated that periodontal fibers have a
great capacity for r e m o d e l i n g and can a c c o m m o -
date to virtually any tooth position if a regional
state of anatomic and physiologic balance exists.
Early writings stressed the i m p o r t a n c e of placing
the teeth in excellent occlusion and holding
t h e m there until the perioral musculature adapts
to the new positions. 81 Lower incisor crowding
which develops postretention has b e e n attrib-
u t e d to a failure of the muscles to adapt.
Mershon 8z stated that the final position of the
teeth was like " a n a r g u m e n t with Mother Na-
ture" who always won. Postretention stability,
one of the major problems facing orthodontists,
was well defined by Hawley8B when he said that
he would gladly give half his fee to anyone who
would be responsible for the retention of his
results after the active appliances are removed.
P a r k e r 84 stated in his article, " R e t e n t i o n - -
Retainers may be forever," that "Experience
does not give wisdom but it may and should
grant perspective." With over 28 years of orth-
odontic experience, G o r m a n 74 explained that
his perspective on retention has changed f r o m
an expectation of universal stability following
bicuspid extraction and 2 years of retention, to
the realization that individual retention plans
must be developed for each patient whether an
extraction or nonextraction treatment regime
was used.
Objectives
T h e objectives of the present study were: (1) to
assess whether significant differences exist be-
tween the p o s t t r e a t m e n t changes experienced in
extraction and nonextraction orthodontic treat-
ments, a n d (2) to d e t e r m i n e the relationship
between these groups and lower incisor irregu-
larity.
Materials and Methods
A r a n d o m sample of 88 subjects was longitudi-
nally studied for changes experienced after ex-
traction and nonextraction treatment. T h e ex-
traction g r o u p consisted mainly of p r e m o l a r
extractions. T h e sample, consisting of extraction
(44%) a n d nonextraction (56%) treated sub-
jects, is set out in Table 1.
164
T a b l e 1. D e s c r i p t i o n o f t h e S a m p l e
Sex
Angle Class (molar)
Skeletal Class (ANB)
Age (years) Sample
Age Nonextraction
Age Extraction
Orthodontic study casts and lateral cephalo-
grams were analyzed for all three stages studied.
Intraobserver error was f o u n d to be less than
1.0%, and itwas concluded that this error had no
effect on the outcome of the results. The study
casts were measured with digital calipers capable
of measuring to 0.01 mm. Measurements o f
sagittal, transverse and vertical dimensions were
included.
Cephalometric measurements were obtained
with the use of the Oliceph c o m p u t e r p r o g r a m
(Orthodontic Logic, Inc., Kansas City, MO) and
included measurements of the popular analyses
of Steiner, 25 Tweed, s5,s6 Ricketts, 27 Bj6rk/Jar-
abak, s7 and Holdaway, 28 with additions such as
the Wits appraisal, ss
The data (extraction and nonextraction) were
subjected to the Wilcoxon and the Chi-square
statistical tests for each of the three treatment
stages studied (T1, T2, and T3). Spearman
correlation coefficients were used to shed light
on the statistical relationships between the vari-
ous variables measured at the three treatment
stages and the Little Irregularity Index 2° ob-
tained in the postretention group, s9 The signifi-
cance level of the study was set at 0.05.
Results
Age differences were minimal at each of the time
intervals with respect to the total sample and
for the extraction and nonextraction groups
(Table 1).
T a b l e 2. Differences in t h e Little Irregularity I n d e x
Between Extraction and Nonextraction Groups
T1
!&riable Mean SD
Extraction Irregu-
larity Index 5.1" 3.9
Nonextraction
Irregularity Index 2.7* 2.1
SD, Standard deviation.
*Statistically significant difference, P < 0.05 (Wilcoxon
2-sample test).
Rossouw, Preston, a n d Lombard
Male (33) Female (55) Total 88
I (24) II (62) III (2)
I (23) II (61) III (4)
T1 11.9 (10.1-14.2) T2 14.7 (11.1-24.2) T3 21.5 (16.2-33.5)
T1 11.8 (_+1.1) T2 14.5 (-+2.0) T3 21.9 (_+3.8)
T1 12.1 (-+1.1) T2 14.9 (+1.5) T3 20.9 (-+3.0)
Ramus height as described by Jarabak and
Fizzel187 was smaller in the extraction group at
T1, T2 and T3. The variables describing the
mandibular growth direction (mandibular plane
angle by Steiner, 25 Tweed, 26 Ricketts, 27 and Jar-
abak and FizzelW; the gonial angle and corpus
sling measurements of Ricketts e t a144; facial
taper by Ricketts27; facial axis angle, mandibular
arc and lower facial height by Ricketts 27) indi-
cated that significantly more vertical growth
occurred in the extraction c o m p a r e d to the
nonextraction g r o u p at T1, T2, and T3. The
mandibular arch length 4° measurements were
less in the extraction group at T1, T2, and T3
( P < 0.05). The lower incisor axial inclina-
tion 25-27 also showed significant differences be-
tween the two groups at the three time intervals.
The mandibular incisors were more upright in
the extraction g r o u p and also closer to the
average values described by the n o t e d analyses
following the active treatment. Mandibular inter-
canine width showed significant differences at
the start of treatment (T1) only. The intercanine
width was slightly expanded in the nonextraction
g r o u p ( m e a n difference T1-T2, 0.55 mm;
P < 0.05) and constricted in the extraction group
(mean difference T1-T2, - 0 . 6 4 mm; P < 0.05).
These intercanine measurements, however, indi-
cate that this dimension was maintained within
clinical norms ( P < 0.05). Both nonextraction
and extraction intercanine dimensions con-
stricted during the T2-T3 period. The Curve of
Spee tended to d e e p e n in the extraction group
following treatment in contrast to the nonextrac-
tion group. This was statistically different at the
postretention phase only (T3).
T2 T3
The Little Irregularity Index 2° revealed signifi-
l~ean SD Mean SD
cant differences at the pretreatment observation
(T1) only. No significant differences were mea-
0.5 0.7 1.7 1.7 sured at the end of the active orthodontic treat-
0.3 0.5 1.7 1.5 m e n t (T2) and at the final observation (T3)
between the two groups (Table 2).
The only u p p e r facial dimension, which indi-
cated a statistical difference, was the anterior
 Extraction ~*~us Nonextraction Treatment
cranial base length, s7 which was shorter in the
extraction group at T2 and T3. Dental arch
width, measured as the maxillary bimolar dimen-
sion showed differences between the groups
t h r o u g h o u t the study (T1-T3), was narrower in
the extraction group. The u p p e r first molar 44
showed more mesial m o v e m e n t in the extraction
group; these differences were measured only at
the end of active treatment (T2).
Assessment of the maxillomandibular relation-
ships indicated a statistically significant differ-
ence between the extraction and nonextraction
groups. One such difference occurred in the
posterior facial height (Sella-gonion) s7 at all
three observation times (T1-T3). Differences in
the posterior facial height also affected the
percentage ratio between the anterior and poste-
rior facial heights (Nasion-menton v Sella-
gonion) which showed significant differences at
all three of the stages studied. The posterior to
anterior face height ratio increased due to a
greater increase in the posterior facial height.
Moreover; the posterior facial height (Sella-
gonion) was smaller in the extraction g r o u p
indicating a more vertical growth pattern. The
Wits appraisal 88 revealed statistically significant
differences only at the c o m m e n c e m e n t of the
treatment (T1) (2.4 m m in nonextraction and
0.3 m m in extraction group).
The occlusal variables which had significant
differences (overjet, overbite and the molar and
canine relationships) did so only at the start of
the treatment (T1).
Soft-tissue parameters that indicated differ-
ences only at the beginning of treatment (T1)
were a less protrusive u p p e r lip to E-line 9° and
lower lip to E-line 9° in the nonextraction group.
The u p p e r lip curl, lower lip to H-line and
inferior lip sulcus to H-line 28 at T1 showed more
protrusive lips in the extraction group. Follow-
ing treatment only the inferior lip sulcus depth
to the H-line 2s displayed statistically significant
differences and then only at the end of treat-
m e n t (T2) and at the end of the postorthodontic
phase (T3), revealing a mean of approximately
1 m m more retrusive lips in the extraction
group.
Discussion
Spectacular results achieved as a result of orth-
odontic treatment are very impressive and greatly
165
admired. The problem lies in the fact that
failures, too, occur often. Treatment reliability,
therefore, depends u p o n p r o o f that the propor-
tion of success is greater than that of failures.
Hellman 71 m e n t i o n e d that to ascertain the rela-
tionship between the successes and the failures
in orthodontics requires long stretches of time.
Although a n u m b e r of long-term studies 4°,77,91
discuss the stability and relapse of posttreatment
orthodontic results, there are still numerous
debates as to whether extraction or nonextrac-
tion therapy produces more stable results.
Does extraction solve all our problems? A very
positive " n o ! " Without meticulous planning,
extraction therapy will result in unwarranted and
unjustifiable failures. 9
The assessment of the data of the present
study indicated certain significant differences
between extraction and nonextraction groups.
The significant difference in age at the end of
treatment (T2) is probably not of any clinical
significance (14.5 years nonextraction and 14.9
years extraction group). The mandibular dimen-
sions, which included the lower intercanine
width, the lower incisor position 25-27, the incisor
irregularity 2°, the arch length and mandibular
growth pattern 25,27,44,s7, all showed significant
differences between the two groups at the start of
treatment (T1). U p p e r bimolar width also showed
similar significant differences with the nonextrac-
tion group consistently having wider measure-
ments c o m p a r e d with the extraction group at
T1-T3. The mensuration of the group differ-
ences of the maxillary to mandibular data at the
start of treatment (T1) also revealed significant
differences. These maxillo-mandibular differ-
ences were the antero-posterior discrepancy
(ANB angle 25 and Wits appraisalSS), the anterior
to posterior facial height ratios s7, overbite and
overjet, as well as molar and canine relation-
ships. 4 Soft tissue variable differences at the start
of treatment included the lower and u p p e r lip to
the E-line 9°, the lower lip to H-line, the u p p e r lip
curl to H-line and the inferior lip sulcus to
H-line. 2s All of these noted significant differ--
ences between the nonextraction and extraction
groups could be expected. They not only justify
the reasons for the differences in treatment
regimes, but also acknowledge the fact that the
orthodontist possibly made the correct decisions
regarding the extraction, or nonextraction ap-
proaches to treatment. The extraction group
166 Rossouw, Preston, and Lombard
showed a more vertical growth direction and
slightly more protrusive soft tissue profile at T1.
The end of active orthodontic treatment (T2)
normally signifies the achievement of ideal occlu-
sal and soft-tissue parameters. The end results of
both the extraction and nonextraction groups
were within acceptable clinical norms as evalu-
ated by the analyses cited. Functional and aes-
thetic results which please both the orthodontist
and the patient symbolizes ultimate success.
The linear measurements indicated that the
lower incisor goals for both groups were at-
tained. The incisor mandibular plane angle
(IMPA) 26 and Point A-pogonion line 27 measure-
ments were within the u p p e r range of the de-
scribed average for the extraction group. The
incisors were also snore upright in the extraction
group and more proclined in the nonextraction
group. The Point A-Pogonion line can be influ-
enced by the chin button shape, a fact that could
be the reason for the slightly more proclined
teeth in the nonextraction group. It is known
that brachycephalic and dolichocephalic facial
patterns, m e n s u r a t e d by m a n d i b u l a r plane
angles, mandibular rotation angles and lower
facial height measurements, do differ in this
respect and that the extraction philosophy is also
different for the two types of facial patterns. 44,s6
Mandibular dimensions are different for vertical
and horizontal growers. Horizontal growers show
a flatter mandibular plane when c o m p a r e d with
the more acute mandibular plane of the vertical
grower which is characterized by strong antego-
nial notching. 44,92 Differences in the arch length
between extraction and nonextraction subjects
were expected. The arch length does not only
decrease because of the natural p h e n o m e n o n of
mesial migration or drifting, 93,94 but also due to
extractions, which caused tremendous differences
in this dimension. This finding supported stud-
ies showing a decrease in arch length. 17,77,7s,95,96
Similar changes occur in untreated individuals. 16
Maxillary variables also showed some ex-
pected significant differences between the extrac-
tion and nonextraction groups. The anterior
cranial base measurement, Sella-Nasion, was sig-
nificantly shorter in the extraction group at the
end of treatment (T2). This finding can be
ascribed to a possible enlargement of the frontal
sinus with an accompanying forward bulging of
the frontal bone in the nonextraction group.
Because of these growth changes, Nasion could
have been displaced forwards. Jacobson ss used
the Wits appraisal of jaw disharmony to show
how different positions of Nasion could influ-
ence the basic grouping of malocclusions. It was
shown in a cross-sectional study that excess
mandibular growth correlates with increases in
frontal sinus size. 97 As was previously noted,
extraction or nonextraction treatment will to
some extent be d e p e n d a n t on the mandibular
morphology. The maxillary bimolar width was
significantly smaller in the extraction group at all
the observation periods (T1-T3), but the mesio-
distal position of the maxillary first molar to the
pterygoid root vertical (PTV) and center of the
cranium (CCV)44 showed significant differences
only at the end of treatment (T2). As the molars
move forwards due to extractions, loss of leeway
or normal growth, it may be expected that these
dimensions (T1, T2 and T3) will change. Extrac-
tion of premolars results in a forward movement
of the molars into a narrower part of the alveolar
trough which results in narrowing of the bimolar
width. The opposite is of course also true when
the first molars are distalized using extraoral
traction. Decreases in arch width have also been
reported in a second premolar extraction study. 76
These observations were also n o t e d in the pre-
sent study.
Anteroposterior maxillomandibular discrepan-
cies may also be influenced by facial patterns
(brachifacial or dolichofacial) or treatment re-
gimes. Extractions for example may cause the
mandibular plane angle to rotate in a forward
closing direction. With headgear and Class II
intermaxillary elastic wear the lower facial height
may be increased. Natural mandibular growth
rotation 9s in the various growth patterns will also
account for differences in extraction and nonex-
traction groups. Because of these rotations the
ratio of anterior and posterior facial heights as
well as the posterior facial height was signifi-
cantly different for the groups (posterior facial
height smaller in the extraction group).
Interestingly enough, the different occlusions
appeared to have been treated to similar occlusal
goals for both groups. The ultimate aim was to
achieve the six keys of occlusion in all the treated
subjects. 99,1°° Good orthodontic technique in
order to achieve these goals is imperative and
played a major role in p r o d u c i n g occlusions with
no significant differences at the end of treatment
(T2) and at the end of the post-orthodontic
 Extraction Versus Nonextraction Treatment
phase (T3). Tooth-size discrepancies 1°1 may be
one the etiologic factors which cause malocclu-
sions as well as lead to the decision to extract 56,57
or to interproximal enamel stripping. 1°2-1°5 No
significant differences were, however, detected
in the Bolton 1°1 relationships between the groups.
Soft-tissue profile assessment is an i m p o r t a n t
aid in total orthodontic evaluation. Soft-tissue
can be grossly influenced if extractions are per-
f o r m e d in a nonextraction facial profile. Hold-
away2s,45 emphasized this fact with his soft-tissue
analysis and visual t r e a t m e n t objective. Initial
significant differences in soft-tissue variables were
expected. Sound diagnosis and subsequent cor-
rectly treated orthodontic subjects should not
necessarily p r o d u c e m a j o r differences in soft
tissue profile, whether treated extraction or non-
extraction. This is b o r n e out by the nonsignifi-
cant differences which was observed between the
groups at the e n d of t r e a t m e n t (T2) and at the
final observation (T3). T h e only soft-tissue vari-
able, showing a significant difference at the end
of t r e a t m e n t and the postretention phase was the
inferior lip sulcus to the H-line. This difference
can be accounted for by the fact that the morphol-
ogy of the chin button, a slight proclination or
retroclination of the lower incisors and an en-
larged overbite or overjet may affect this dimen-
sion. T h e m e a n lower incisor axial inclination
was slightly proclined in this study during the
orthodontic t r e a t m e n t (especially in the nonex-
traction group), although the millimetric dis-
tance of the incisor tip to the various lines (NB 25
and A P o 27) was within norms.
An analogy suggesting that teeth move as long
as we live,just as surely as o u r hair color changes
t h r o u g h o u t our lives, possibly explains some of
the p o s t t r e a t m e n t changes measured. 84 Changes
in the parameters of this study between the end
of t r e a t m e n t (T2) and the end of the postortho-
dontic phase (T3) indicated the r e b o u n d or
relapse so often r e f e r r e d to in the litera-
ture. 17,75,76,91,95
Similar differences, which o c c u r r e d in the
mesial positions of the first maxillary molars at
end of t r e a t m e n t (T2), were also significant
when m e a s u r e d at the final observation (T3) for
the two groups. T h e only variables, which be-
came nonsignificant were d e p e n d e n t on the
m o v e m e n t of the first molars. Some settling or
r e b o u n d m o v e m e n t obviously took place a n d in
so doing eliminated the previous differences
167
(end of treatment) between the two groups. An
analysis of variance showed that the m o l a r posi-
tions f r o m the e n d of t r e a t m e n t to the final
observation (T2-T3), however, r e m a i n e d reason-
ably stable. No significant changes o c c u r r e d
after the achievement of the p o s t t r e a t m e n t mo-
lar and canine relationships. Behrents et al 1°6
r e p o r t e d similar findings.
Extractionists and nonextractionists can show
excellent results and offer persuasive arguments
for their philosophies. Extractionists will usually
rely on the lower incisor position as their key
cephalometric m e a s u r e m e n t ] °7,~°8 T h e nonex-
tractionist again will likely focus on an articula-
tion where all the teeth are m a d e to fit. These
orthodontists will s o m e t i m e s " d e v e l o p " the
arches by starting the t r e a t m e n t with functional
appliances in the early m i x e d dentition. If the
teeth are, irrespective of the type of treatment,
correctly placed for the individual, good aesthet-
ics will follow, the finished dentition will be
stable and facial h a r m o n y will be achieved.
Both orthodontist and patient seek the aes-
thetic rewards of straight teeth and a gorgeous
smile following orthodontic treatment. Ortho-
dontists, however, have the a d d e d responsibility
of achieving functional occlusions. If this har-
m o n y is achieved, one may well be on the way to
achieving long-term stability. 43
Early intervention for the correction of ortho-
dontic p r o b l e m s has b e e n a neglected phase of
orthodontic t r e a t m e n t for too long a time. 81
Being able to clinically assess young orthodontic
subjects a n d realizing the use of natural spaces
available, including the primate and the leeway
spaces, ~°9 will certainly enable m a n y occlusions
to be treated nonextraction. T h e responsibility
in educating new dentists and orthodontists in
this philosophy cannot be overemphasized. Early
interceptive t r e a t m e n t and preserving natural
spaces may be the mainstay for future general
dental practice.
T h e index used in this study to d e t e r m i n e
lower incisor alignment, the Little Irregularity
Index, 2° indicated a m o r e severe situation for the
extraction g r o u p at T1. This showed that the
correct diagnosis was m a d e in treating with
extractions. A value of practically zero was
achieved at the e n d of active t r e a t m e n t (T2). A
slight relapse o c c u r r e d in b o t h groups, but no
significant difference was shown in the lower
incisor irregularity at T2 and T3 (Table 2). T h e
168 Rossouw, Preston, and Lombard
relapse or rebound as indicated from T2 to T3
was well within clinically acceptable standards, z°
Both groups showed similar changes. Moreover,
it can be concluded that when competent ortho-
dontists select an extraction, or nonextraction
orthodontic treatment regime for the correction
of malocclusions, there need not be any signifi-
cant differences between the posttreatment re-
sults of the groups.
Conclusion
1. The extraction of teeth does not necessar-
ily assure long-term stability of the lower
incisors, however, clinically stable results
can be achieved as shown in this study.
2. The differences e x p e r i e n c e d between ex-
traction and nonextraction groups were
mainly maxillary and mandibular dimen-
sional as well as growth pattern differ-
ences.
3. The Little Irregularity Index 2° showed no
significant ( P > 0.05) differences be-
tween the extraction and nonextraction
groups at T2 and T3.
4. Meticulous orthodontic care, including
proper diagnosis in order to distinguish
between extraction and nonextraction
malocclusions, is imperative.
5. Orthodontic technique, including reten-
tion management, appears to play an
important role in achieving physiologi-
cally stable results.
6. The extraction versus nonextraction con-
troversy seems to be here to stay.
7. Patients must be informed o f the benefits
and disadvantages of both treatment regi-
mens.
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