ORIGINAL ARTICLE

Effects of extraction and nonextraction therapy

with air-rotor stripping on facial esthetics in
postadolescent borderline patients
Derya Germeça and Tulin Ugur Tanerb
Ankara, Turkey

Introduction: A prospective randomized study was designed to compare the skeletal, dental, and soft-tissue
profile changes in Class I borderline patients treated with extraction and nonextraction by means of the
air-rotor stripping (ARS) technique and to compare the treatment times. Methods: Twenty-six borderline
patients with balanced and orthognathic facial profiles were randomly divided into 2 groups. In the first
group, 13 subjects with a mean age of 18.1 ⫾ 3.7 years and mean maxillary and mandibular crowding of
5.7 ⫾ 1.5 and 5.9 ⫾ 1.4 mm, respectively, were treated by removal of 4 premolars with minimum anchorage.
In the second group, 13 subjects with a mean age of 17.8 ⫾ 2.4 years and mean maxillary and mandibular
crowding of 5.0 ⫾ 1.3 and 5.9 ⫾ 1.3 mm, respectively, were treated with ARS. Lateral cephalometric
radiographs and dental models taken before and after treatment were evaluated. Results: The initial skeletal,
dental, and profile characteristics of both groups were similar. In the first group, the maxillary and mandibular
incisors were slightly retracted, whereas lip positions did not change. In the nonextraction group,
maintenance of maxillary incisor position, slight protrusion of the mandibular incisors and the upper and
lower lips were observed at the end of treatment. The nasolabial angle decreased significantly. Because of
postpubertal growth of the nose and the chin, the lips appeared slightly retrusive after extraction therapy,
whereas lip protrusion was compensated in the nonextraction group. The main soft-tissue profile differences
between the 2 groups were 1 to 1.5 mm more retruded upper and lower lip positions in the extraction
patients, but both groups had well-balanced and desirable facial esthetics with all profile measurements
within normal limits. Nonextraction therapy with ARS reduced treatment time by 8 months. Conclusions:
Both extraction and ARS combined with nonextraction therapies are effective treatment alternatives for Class
I borderline patients with good facial profile and moderate dental crowding. (Am J Orthod Dentofacial Orthop
2008;133:539-49)

A
balanced and harmonious facial profile is a
major treatment goal in contemporary orth-
odontics. The interaction between orthodontics
and facial profile esthetics has been investigated for
years.1-20 The results of many studies showed that some
orthodontic procedures including extraction can influ-
ence the soft-tissue profile. On the other hand, the
consequences of extraction therapy are still controver-
sial. Some authors3,13,15,16 reported that the extraction
of premolars led to unchanged or improved facial
profiles, but a few authors21-23 suggested that this
treatment approach resulted in undesirably flattened
From the Department of Orthodontics, Faculty of Dentistry, Hacettepe Univer-
sity, Ankara, Turkey.
a
Research assistant.
b
Professor.
Reprint requests to: Derya Germeç, Yeditepe University, Faculty of Dentistry,
Department of Orthodontics, Bagdat cad. No 238 Goztepe 34728, Istanbul,
Turkey; e-mail, dgermec@gmail.com.
Submitted, January 2006; revised and accepted, April 2006.
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.04.052
facial appearance. Although the percentage of patients
with “dished-in” profiles after extraction treatment was
found to be very small,3,8 the detrimental effect of tooth
extraction on the facial profile is a common belief
among orthodontists. This view led to reduced extrac-
tion rates in recent years and to the increasing tendency
for nonextraction therapies such as lateral, anterior, and
posterior expansion of the dentition or stripping.24 As
an alternative to tooth extraction in patients with
moderate crowding, air-rotor stripping (ARS) was pro-
posed by Sheridan.25 However, the effects of nonex-
traction treatment combined with ARS on the facial
profile have not been clarified.
Most studies evaluating facial profile changes from
extraction or nonextraction orthodontic treatment were
carried out on Class II patients.1,2,4,6,8,10-12,17,26,27 Al-
though Class I maloclusions with crowding are com-
mon, only a few investigations compared the effects of
extraction vs nonextraction therapy in Class I pa-
tients.9,18,19 In general, clear-cut extraction and nonex-
traction patients were the focus of these studies. How-
539
540 Germeç and Taner
Table I. Sex distribution, mean ages, and dental crowding amounts of the subjects
Age (y)
Male (n) Female (n) Total (n) Mean ⫾ SD
Extraction 2 11 13 18.1 ⫾ 3.7
Nonextraction 2 11 13 17.8 ⫾ 2.4
ever, as mentioned by Paquette et al,4 the comparison
between extraction and nonextraction therapies would
have meaning only for borderline patients who could be
treated either way.
Furthermore, a challenging problem in orthodontics
is how to treat borderline patients with moderate
crowding and good facial balance without causing
negative effects on the face. The major concern is
whether an extraction approach would contribute to an
undesirable facial appearance or whether nonextraction
therapy would result in poor stability and a protrusive
profile for borderline patients.28 The orthodontic liter-
ature provides no evidence for this belief because
studies comparing the effects of extraction and nonex-
traction treatments on dentoskeletal structures and fa-
cial profile in Class I borderline patients are lacking.
This prospective study was designed to supply
documentation on the orthodontic treatment alterna-
tives of Angle Class I borderline patients. The aims
were to compare the skeletal, dental, and soft-tissue
profile changes in Class I borderline patients treated
with extraction or nonextraction with ARS and to
compare treatment times.
MATERIAL AND METHODS
The sample consisted of 26 borderline Angle Class
I patients who could have been treated either with or
without extraction; they had moderate dental arch
crowding, and balanced facial profiles and dentoskel-
etal relationships. The selection criteria were as fol-
lows: (1) orthognathic facial profile, moderate maxil-
lary and mandibular dental arch crowding, and Angle
Class I molar relationship; (2) no skeletal discrepancies
or congenitally missing teeth; and (3) completed pu-
bertal growth spurt.
This study was approved by the Ethical Committee
of the Hacettepe University Medical School.
Patients referred to the orthodontic clinic during a
4-year period were evaluated by experienced orthodon-
tists using intraoral and extraoral photographs and
cephalometric and model analyses. Borderline patients
meeting the selection criteria were informed about the
2 treatment alternatives, extraction and nonextraction
with ARS. Informed consent was obtained from each
patient before orthodontic treatment. Those who did not
American Journal of Orthodontics and Dentofacial Orthopedics
April 2008
Maxillary crowding (mm) Mandibular crowding (mm)
Mean ⫾ SD Mean ⫾ SD
⫺5.7 ⫾ 1.5 ⫺5.9 ⫾ 1.4
⫺5.0 ⫾ 1.3 ⫺5.9 ⫾ 1.3
want to participate were excluded. Patients who ac-
cepted the treatment were randomly divided into 2
groups in the order of their referral to the orthodontic
clinic: the first patient was assigned to the extraction
group, and the next one to the nonextraction group. In
the first group, 13 patients were treated with the
removal of 4 premolars. Maxillary and mandibular first
premolars were extracted in 10 patients, and maxillary
and mandibular second premolars were extracted in 3
patients. In the second group, crowding was resolved
with the ARS technique. No expansion appliances were
used in any group. Sex distributions, mean ages, and
dental crowding amounts of the subjects in both groups
are shown in Table I.
After the premolar extractions, the treatment started
with sectional canine distalization. No anchorage prep-
aration was made during segmental canine distaliza-
tion. After the elimination of crowding, the remaining
extraction spaces were closed with increased labial
crown torqued archwires. All anterior teeth were tied
together to increase anterior anchorage and to allow
mesialization of the posterior teeth rather than retrac-
tion of the anterior teeth.
Before ARS, enamel thickness of the teeth was
evaluated on bite-wing radiographs. The ARS tech-
nique was used on both posterior and anterior teeth with
a specially designed ARS bur kit (Raintree Essix,
Metairie, La). A segmental approach was preferred to
eliminate excessive protrusion of incisors. At the be-
ginning of orthodontic treatment, the posterior teeth
were leveled, and separators were placed between the
first molars and the second premolars. After separation,
the enamel on the mesial side of the first molars and the
distal side of the second premolars was reduced with
699 LC crosscut fissure tungsten carbide burs (Raintree
Essix) and finished with finishing diamond burs and
Extrathin medium and Extrathin fine Sof-Lex polishing
discs (3M Dental Products, St Paul, Minn). An in-vitro
study showed that smooth enamel surfaces could be
obtained with the 699 LC crosscut fissure tungsten
carbide bur for stripping.29 The second premolars were
distalized by using open-push coils into the space
obtained by stripping, and the anterior anchorage was
reinforced with an anterior Essix plate. Then this
procedure was continued from posterior to anterior
American Journal of Orthodontics and Dentofacial Orthopedics Germeç and Taner 541
Volume 133, Number 4

Table II. Cephalometric landmarks used to evaluate changes in skeletal and dental structures and soft tissues
Point Description

Na, nasion Most anterior point of the frontonasal suture in the midsagittal plane
S, sella Center of the pituitary fossa of the sphenoid bone
Po, porion Most superior point of the external auditory meatus
Or, orbitale Lowest point in the inferior margin of the orbit
Ptv, Ptv point Most distal point of the pterygopalatine fossa
ANS, anterior nasal spine Tip of the anterior nasal spine
PNS, posterior nasal spine Tip of the posterior nasal spine
R1 Most concave point on the anterior border of the ramus
R2 Antagonist of R1 on the posterior border of the ramus
R3 Most inferior border along the top of the ramus
R4 Antagonist of R3 on the lower border of the ramus
Xi Center of the mandibular ramus
A, Point A Most posterior point in the concavity between ANS and the dental alveolus
B, Point B Most posterior point in the concavity along the anterior border of the symphysis
Go, gonion Most convex point along the inferior border of the ramus
Me, menton Most inferior point of the symphysis
Pog, pogonion Most anterior point on the midsagittal symphysis
Pm, suprapogonion Midpoint of the curve between B and Pog
U1i Tip of the maxillary central incisor
U1a Root apex of the maxillary central incisor
L1i Tip of the mandibular central incisor
L1a Root apex of the mandibular central incisor
U6m Most mesial point of the maxillary first molar
L6m Most mesial point of the mandibular first molar
Pn, pronasale Tip of the nose
Sn, subnasale Point at junction of columella and upper lip
Sls, superior labial sulcus Most posterior point in the concavity between Sn and the upper lip
Ls, labrale superior Most anterior point on the curve of the upper lip
Lsp, labrale superior posterior Most posterior point of the upper lip
Li, labrale inferior Most anterior point on the curve of the lower lip
Lip, labrale inferior posterior Most posterior point of the lower lip
Ils, inferior labial sulcus Most posterior point in the concavity between the lower lip and the chin
Pog=, soft-tissue pogonion Most anterior point of the soft-tissue chin

teeth. When the canines were distalized, the incisors
were bonded and stripped with fine diamond burs
(55000; Raintree Essix). Topical fluoride gel was ap-
plied after stripping, and the subjects were advised to
use fluoride mouth rinse during their orthodontic ther-
apy.
At the end of extraction and nonextraction treatment,
all patients were successfully treated (ie, displayed good
occlusion with Class I canine and molar relationships and
without crowding or extraction spaces).
The Hays-Nance analysis was used to calculate the
amounts of maxillary and mandibular crowding on the
dental casts taken before treatment. In the nonextrac-
tion group, the amount of stripping was calculated by
substracting the posttreatment mesiodistal dimensions
of the teeth from the pretreatment dimensions.
Pretreatment and posttreatment lateral cephalo-
grams were obtained with the same cephalometric
device and the patient standing with the teeth in
occlusion and the lips relaxed. All cephalograms were
traced by the same author (D.G.). The cephalometric
landmarks, lines, and measurements we used to evalu-
ate the changes in dentoskeletal structures and soft
tissues are described in Tables II through IV. Linear
and angular skeletal, dental, and soft-tissue measure-
ments are shown in Figures 1 through 3.
All statistical analyses were performed with the
SPSS software package (SPSS for Windows 98, ver-
sion 10.0; SPSS, Chicago, Ill). For each variable, the
arithmetic mean and standard deviation were calcu-
lated. The Wilcoxon test was used to evaluate treatment
changes in each group. The Mann-Whitney U test was
performed to compare the pretreatment values between
the 2 groups and their treatment changes.
Two weeks after the first measurements, 14
randomly selected lateral cephalograms were re-
traced and remeasured by the same examiner. Ran-
dom error was calculated with Dahlberg’s formula.30
Method errors of the cephalometric variables were
less than 0.5 mm for linear and 0.8° for angular
542 Germeç and Taner American Journal of Orthodontics and Dentofacial Orthopedics
April 2008

Table III. Cephalometric lines used to evaluate changes in skeletal dental structures and soft tissues
Line Description

SN line Line from S to Na

Frankfort horizontal plane (Po-Or) Horizontal plane running through Po and Or
Palatal plane Horizontal plane running through ANS and PNS
Xi-ANS line Line from Xi to ANS
Xi-Pm line Line from Xi to Pm
Mandibular plane Plane running through Go and Me
NA line Line between Na and point A
NB line Line between Na and point B
Pterygoid vertical plane (PTV) Line perpendicular to Frankfort horizontal plane passing through Ptv point
Axial inclination of maxillary incisor Line between U1i and U1a
Axial inclination of mandibular incisor Line between L1i and L1a
Esthetic plane (E-plane) Plane passing through Pn and Pog=
Subnasale-soft-tissue pogonion plane Plane passing through Sn and Pog=
Columella tangent Line tangent to the lower border of the nose extending from Sn
Subnasale-labrale superior line Line between Sn and Ls
Subnasale-superior labial sulcus line Line between Sn and Sls
Superior labial sulcus-labrale superior line Line between Sls and Ls
Labrale inferior-inferior labial sulcus line Line between Li and Ils
Inferior labial sulcus-soft-tissue pogonion line Line between Ils and Pog=
H plane Plane running through Ls and Pog=

Table IV. Cephalometric measurements used to evaluate changes in skeletal dental structures and soft tissues
Measurement Description

1. FMA Angle formed by Frankfort horizontal plane and mandibular plane

2. Lower facial height Angle formed by Xi-ANS and Xi-Pm
3. SNA Angle formed by SN and NA
4. SNB Angle formed by SN and NB
5. ANB Angle formed by NA and NB
6. Pog-NB Distance between Pog and NB line
7. U1-SN Angle formed by the axial inclination of the maxillary incisor and SN
8. U1-NA Angle formed by the axial inclination of the maxillary incisor and NA
9. U1i-PTV Distance between U1i and the PTV line
10. U6m-PTV Distance between U6m and the PTV line
11. IMPA Angle formed by the axial inclination of the mandibular incisor and the mandibular plane
12. L1-NB Angle formed by the axial inclination of mandibular incisor and NB
13. L1i-PTV Distance between L1i and the PTV line
14. L6m-PTV Distance between L6m and the PTV line
15. Overjet Distance between U1i and L1i in the horizontal plane
16. Overbite Distance between U1i and L1i in the vertical plane
17. Nasolabial angle Angle formed by columella tangent and Sn-Ls line
18. Maxillary sulcus contour Angle formed by Sn-Sls line and Sls-Ls line
19. Mandibular sulcus contour Angle formed by Li-Ils line and Ils-Pog= line
20. Pn-PTV Distance from Pn to the PTV line
21. Sls-PTV Distance from Sls to the PTV line
22. Ls-PTV Distance from Ls to the PTV line
23. Li-PTV Distance from Li to the PTV line
24. Ils-PTV Distance from Ils to the PTV line
25. Pog=-Ptv Distance from Pog= to the PTV line
26. Superior sulcus depth Distance from Sls to the tangent to Ls, perpendicular to the Frankfort horizontal plane
27. Ls-SnPog= Distance from Ls to the SnPog= plane
28. Ls-E-plane Distance from Ls to the E-line
29. Ls thickness Distance from Ls to Lsp, parallel to the Frankfort horizontal plane
30. Li-SnPog= Distance from Li to the SnPog= plane
31. Li-E plane Distance from Li to the E-line
32. Li thickness Distance from Li to Lip, parallel to the Frankfort horizontal plane
33. Inferior sulcus depth Distance from Ils to H plane
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 4
Fig 1. Linear and angular skeletal and dental cephalo-
metric measurements.
Fig 2. Angular and linear cephalometric soft-tissue
measurements relative to the PTV line.
measurements, respectively (Table V). The paired t
test was used to detect possible systematic errors. No
statistically significant differences between the first
and second measurements for any variable were
found (P ⬍.05).
Germeç and Taner 543
Fig 3. Linear cephalometric soft-tissue measurements.
RESULTS
No significant differences were observed between
the extraction and nonextraction groups before treat-
ment in terms of age, crowding, or skeletodental and
soft-tissue measurements (Table VI).
Treatment changes in the extraction group
Table VII gives the descriptive statistics for changes
during orthodontic treatment in skeletal, dental, and
soft-tissue measurements of the extraction group. Sig-
nificant treatment changes were found in Pog-NB (0.5
⫾ 0.8 mm, P ⬍.05). U1-SN (⫺5.3° ⫾ 5.9°, P ⬍.05),
U1-NA (⫺5.5° ⫾ 6.5°, P ⬍.05), and U1i-PTV (⫺1.6
⫾ 2.4 mm, P ⬍.05) were significantly decreased.
U6m-PTV was significantly increased with a mean
value of 3.3 ⫾ 1.6 mm (P ⬍.01). IMPA (⫺6.3° ⫾ 3.8°,
P ⬍.01), L1-NB (⫺6° ⫾ 3.7°, P ⬍.01), and L1i-PTV
(⫺1.9 ⫾ 1.9 mm) were significantly decreased. L6m-
PTV was significantly increased with a mean value of
3.5 ⫾ 1.5 mm (P ⬍.01).
A significant increase was found in Ls-E during
orthodontic treatment (⫺1.0 ⫾ 1.6 mm, P ⬍.05).
Li-SnPog= was significantly decreased (⫺1.2 ⫾ 1.5
mm, P ⬍.05), whereas Li-E was significantly increased
(⫺1.2 ⫾ 1.4 mm, P ⬍.05). Significant increases were
found in Li thickness and inferior sulcus depth with
mean values of 1.2 ⫾ 1.4 mm (P ⬍.01) and 0.6 ⫾ 0.6
mm (P ⬍.05), respectively. Pn-PTV (1.2 ⫾ 1.3 mm,
544 Germeç and Taner American Journal of Orthodontics and Dentofacial Orthopedics
April 2008

Table V. Method error measurements Table VI. Comparison of ages and dental cast and
cephalometric measurements between groups
Method error
Extraction Nonextraction
1. FMA (°) 0.77 (n ⫽ 13) (n ⫽ 13)
2. Lower facial height (°) 0.79 Mean ⫾ SD Mean ⫾ SD P
3. SNA (°) 0.67
4. SNB (°) 0.58 Age (y) 18.1 ⫾ 3.7 17.8 ⫾ 2.4 .663
5. ANB (°) 0.52 Maxillary crowding (mm) ⫺5.7 ⫾ 1.5 ⫺5.0 ⫾ 1.3 .171
6. Pog-NB (mm) 0.38 Mandibular crowding (mm) ⫺5.9 ⫾ 1.4 ⫺5.9 ⫾ 1.3 .876
7. U1-SN (°) 0.67 1. FMA (°) 24.5 ⫾ 3.9 25.9 ⫾ 4.3 .341
8. U1-NA (°) 0.73 2. Lower facial height (°) 46.4 ⫾ 2.3 46.4 ⫾ 2.9 .979
9. U1i-PTV (mm) 0.33 3. SNA (°) 79.5 ⫾ 3.6 78.4 ⫾ 3.3 .409
10. U6-PTV (mm) 0.52 4. SNB (°) 77.2 ⫾ 2.2 76.2 ⫾ 2.7 .280
11. IMPA (°) 0.55 5. ANB (°) 2.4 ⫾ 1.8 2.2 ⫾ 1.3 .816
12. L1-NB (°) 0.62 6. Pog-NB (mm) 2.0 ⫾ 1.6 2.5 ⫾ 1.9 .501
13. L1i-PTV (mm) 0.31 7. U1-SN (°) 104.1 ⫾ 2.8 103.3 ⫾ 6.5 .269
14. L6m-PTV (mm) 0.49 8. U1-NA (°) 24.4 ⫾ 5.3 24.7 ⫾ 5.6 .857
15. Overjet (mm) 0.21 9. U1i-PTV (mm) 58.4 ⫾ 3.9 58.9 ⫾ 4.9 .487
16. Overbite (mm) 0.33 10. U6-PTV (mm) 30.1 ⫾ 2.8 29.5 ⫾ 3.7 .797
17. Nasolabial angle (°) 0.28 11. IMPA (°) 94.9 ⫾ 6.9 92.9 ⫾ 5.5 .316
18. Maxillary sulcus contour (°) 0.23 12. L1-NB (°) 26.8 ⫾ 4.2 24.9 ⫾ 3.3 .199
19. Mandibular sulcus contour (°) 0.34 13. L1i-PTV (mm) 55.4 ⫾ 3.5 55.4 ⫾ 4.3 .797
20. Pn-PTV (mm) 0.40 14. L6-PTV (mm) 31.4 ⫾ 3.3 30.8 ⫾ 3.6 .877
21. Sls-PTV (mm) 0.23 15. Overjet (mm) 3.1 ⫾ 0.8 3.9 ⫾ 1.3 .093
22. Ls-PTV (mm) 0.16 16. Overbite (mm) 2.4 ⫾ 1.6 3.3 ⫾ 1.1 .161
23. Li-PTV (mm) 0.19 17. Nasolabial angle (°) 108.5 ⫾ 8.9 113.1 ⫾ 9.5 .383
24. Ils-PTV (mm) 0.23 18. Maxillary sulcus
25. Pog=-PTV (mm) 0.31 contour (°) 144.3 ⫾ 9.9 142.6 ⫾ 11.6 .918
26. Superior sulcus depth (mm) 0.39 19. Mandibular sulcus
27. Ls-SnPog= (mm) 0.19 contour (°) 138.0 ⫾ 11.6 139.3 ⫾ 11.8 .663
28. Ls-E-plane (mm) 0.13 20. Pn-PTV (mm) 86.4 ⫾ 3.9 87.5 ⫾ 5.9 .778
29. Ls thickness (mm) 0.33 21. Sls-PTV (mm) 68.5 ⫾ 3.2 68.8 ⫾ 4.6 .778
30. Li-SnPog= (mm) 0.21 22. Ls-PTV (mm) 71.1 ⫾ 3.3 71.2 ⫾ 4.4 .857
31. Li-E-plane (mm) 0.16 23. Li-PTV (mm) 69.0 ⫾ 4.0 68.7 ⫾ 4.8 .797
32. Li thickness (mm) 0.23 24. Ils-PTV (mm) 61.1 ⫾ 4.3 60.5 ⫾ 4.6 .858
33. Inferior sulcus depth (mm) 0.27 25. Pog=-PTV (mm) 61.4 ⫾ 4.6 61.0 ⫾ 6.0 .799
26. Superior sulcus depth
(mm) 2.7 ⫾ 0.8 2.5 ⫾ 1.2 .855
27. Ls-SnPog= (mm) 2.2 ⫾ 1.3 1.9 ⫾ 1.2 .469
P ⬍.05) and Pog=-PTV (2.2 ⫾ 3.9 mm, P ⬍.05) were 28. Ls-E-plane (mm) ⫺5.4 ⫾ 1.7 ⫺5.4 ⫾ 1.8 .918
significantly increased after extraction therapy. 29. Ls thickness (mm) 11.9 ⫾ 1.7 11.0 ⫾ 1.1 .149
30. Li-SnPog= (mm) 2.5 ⫾ 1.6 2.2 ⫾ 1.1 .535
Treatment changes in the nonextraction group 31. Li-E-plane (mm) –2.4 ⫾ 1.6 ⫺2.6 ⫾ 1.7 .917
32. Li thickness (mm) 14.4 ⫾ 3.0 14.9 ⫾ 1.9 .410
Table VIII shows the descriptive statistics for changes 33. Inferior sulcus depth
during orthodontic treatment in skeletal, dental, and (mm) 4.6 ⫾ 2.1 4.5 ⫾ 1.6 .777
soft-tissue measurements of the nonextraction group.
U6m-PTV was significantly increased with a mean
value of 0.7 ⫾ 0.5 mm (P ⬍.01). L1-NB and L1i-PTV The comparison of treatment changes between both
were significantly increased with mean values of 1.6° groups is shown in Table IX. The change in U1i-PTV
⫾ 2.0° (P ⬍.05) and 1.4 ⫾ 1.2 mm (P ⬍.05), during treatment was significantly different between the
respectively. A significant increase was also found in groups (P ⬍.01). In the extraction group, the mandibular
L6m-PTV (P ⬍.01). Overjet was significantly decreased incisors showed retroclination, whereas in the nonextrac-
after nonextraction treatment (⫺1.1 ⫾ 0.7 mm, P ⬍.01). tion group slight proclination was noted. The changes in
The nasolabial angle showed a significant decrease mandibular incisor inclination and position (IMPA, L1-
(⫺3.0° ⫾ 5.0°, P ⬍.05). Ls thickness was significantly NB, and L1i-PTV) were significantly different (P ⬍.001)
increased with a mean value of 1.1 ⫾ 1.1 mm (P ⬍.05). between the 2 groups. Significant differences were found
A slight but significant increase was also observed in in U6m-PTV and L6m-PTV between groups (P ⬍.001).
Li-SnPog= (0.7 ⫾ 1.1 mm, P ⬍.05). All soft-tissue PTV Significant differences were also observed in upper and
distances were significantly increased except for Ils-PTV. lower lip positions between the groups.
American Journal of Orthodontics and Dentofacial Orthopedics Germeç and Taner 545
Volume 133, Number 4

Table VII. Treatment changes in the extraction group (n ⫽ 13)

Pretreatment Posttreatment Difference
Mean ⫾ SD Mean ⫾ SD Mean ⫾ SD P

1. FMA (°) 24.5 ⫾ 3.9 24.3 ⫾ 4.1 ⫺0.2 ⫾ 0.8 .186

2. Lower facial height (°) 46.4 ⫾ 2.3 46.3 ⫾ 2.4 ⫺0.1 ⫾ 1.0 .765
3. SNA (°) 79.5 ⫾ 3.6 79.5 ⫾ 2.9 0 ⫾ 1.5 .821
4. SNB (°) 77.2 ⫾ 2.2 76.9 ⫾ 2.5 ⫺0.3 ⫾ 1.1 .490
5. ANB (°) 2.4 ⫾ 1.8 2.6 ⫾ 1.3 0.3 ⫾ 1.3 .762
6. Pog-NB (mm) 2.0 ⫾ 1.6 2.5 ⫾ 2.0 0.5 ⫾ 0.8 .027*
7. U1-SN (°) 104.1 ⫾ 2.8 98.8 ⫾ 5.7 ⫺5.3 ⫾ 5.9 .013*
8. U1-NA (°) 24.4 ⫾ 5.3 18.9 ⫾ 5.3 ⫺5.5 ⫾ 6.5 .015*
9. U1i-PTV (mm) 58.4 ⫾ 3.9 56.8 ⫾ 3.3 ⫺1.6 ⫾ 2.4 .032*
10. U6m-PTV (mm) 30.1 ⫾ 2.8 33.4 ⫾ 2.7 3.3 ⫾ 1.6 .002†
11. IMPA (°) 94.9 ⫾ 6.9 88.7 ⫾ 6.3 ⫺6.3 ⫾ 3.8 .002†
12. L1-NB (°) 26.8 ⫾ 4.2 20.9 ⫾ 4.7 ⫺6.0 ⫾ 3.7 .002†
13. L1i-PTV (mm) 55.4 ⫾ 3.5 53.5 ⫾ 3.2 ⫺1.9 ⫾ 1.9 .006†
14. L6m-PTV (mm) 31.4 ⫾ 3.3 34.9 ⫾ 3.3 3.5 ⫾ 1.5 .002†
15. Overjet (mm) 3.1 ⫾ 0.8 2.9 ⫾ 0.8 ⫺0.2 ⫾ 1.2 .578
16. Overbite (mm) 2.4 ⫾ 1.6 3.0 ⫾ 0.9 0.7 ⫾ 1.7 .280
17. Nasolabial angle (°) 108.5 ⫾ 8.9 109.9 ⫾ 10.4 1.4 ⫾ 6.3 .366
18. Maxillary sulcus contour (°) 144.3 ⫾ 9.9 140.7 ⫾ 8.9 ⫺3.6 ⫾ 7.4 .108
19. Mandibular sulcus contour (°) 138.0 ⫾ 11.6 135.5 ⫾ 8.5 ⫺2.5 ⫾ 5.8 .208
20. Pn-PTV (mm) 86.4 ⫾ 3.9 87.6 ⫾ 3.8 1.2 ⫾ 1.3 .015*
21. Sls-PTV (mm) 68.5 ⫾ 3.2 68.5 ⫾ 3.2 0.0 ⫾ 1.8 .964
22. Ls-PTV (mm) 71.1 ⫾ 3.3 71.0 ⫾ 3.5 ⫺0.1 ⫾ 2.4 .721
23. Li-PTV (mm) 69.0 ⫾ 4.0 68.9 ⫾ 4.0 ⫺0.1 ⫾ 2.5 .479
24. Ils-PTV (mm) 61.1 ⫾ 4.3 61.2 ⫾ 3.9 0.1 ⫾ 2.1 .929
25. Pog=-PTV (mm) 61.4 ⫾ 4.6 63.5 ⫾ 3.9 2.2 ⫾ 3.9 .034*
26. Superior sulcus depth (mm) 2.7 ⫾ 0.8 2.7 ⫾ 0.9 0.0 ⫾ 0.9 1.000
27. Ls-SnPog= (mm) 2.2 ⫾ 1.3 1.4 ⫾ 1.6 ⫺0.8 ⫾ 1.4 .076
28. Ls-E-plane (mm) ⫺5.4 ⫾ 1.7 ⫺6.4 ⫾ 1.8 ⫺1.0 ⫾ 1.6 .046*
29. Ls thickness (mm) 11.9 ⫾ 1.7 12.8 ⫾ 2.0 0.9 ⫾ 2.2 .207
30. Li-SnPog= (mm) 2.5 ⫾ 1.6 1.4 ⫾ 2.1 ⫺1.2 ⫾ 1.5 .027*
31. Li-E-plane (mm) ⫺2.4 ⫾ 1.6 ⫺3.6 ⫾ 2.1 ⫺1.2 ⫾ 1.4 .013*
32. Li thickness (mm) 14.4 ⫾ 3.0 15.6 ⫾ 3.3 1.2 ⫾ 1.4 .008†
33. Inferior sulcus depth (mm) 4.6 ⫾ 2.1 5.2 ⫾ 1.8 0.6 ⫾ 0.6 .011*

*P ⬍.05; †P ⬍.01.

The comparison of treatment times between groups
showed that treatment time in the nonextraction group
(17.0 ⫾ 4.6 months) was significantly less than in the
extraction group (24.8 ⫾ 6.9 months) (P ⬍.01) (Table
IX).
The amount of reduction obtained by ARS was
5.4 ⫾ 1.7 mm for the maxillary teeth (2.6 ⫾ 0.9 mm for
anterior and 2.8 ⫾ 1.0 mm for posterior) and 5.1 ⫾ 0.9
mm for mandibular teeth (2.0 ⫾ 0.5 mm for anterior
and 3.1 ⫾ 0.9 mm for posterior).
DISCUSSION
An important question to be answered in borderline
cases is whether the treatment of choice will result in
undesirable profile changes.28,31 In borderline patients
with good facial balance and moderate crowding, the
main problems are how to close the remaining spaces
after extraction therapy or how to gain space for
decrowding of the dental irregularity without causing
detrimental effects on the facial profile. Therefore,
orthodontic treatment mechanics and anchorage prepa-
ration have utmost importance for satisfactory results.28
In the extraction group of this study, the treatment
mechanics were designed to loosen posterior anchor-
age, whereas in the nonextraction group the required
space was gained by ARS without significant transverse
and anteroposterior expansion. The aim of this spe-
cially designed study in terms of treatment mechanics,
anchorage preparation, and space management was to
compare the treatment effects of extraction and nonex-
traction with ARS on dentoskeletal structures and facial
profiles in Class I borderline patients who could have
been treated either way.
No significant differences in age, maxillary and
mandibular crowding, or skeletal, dental, and profile
measurements were observed between the extraction
and nonextraction groups before treatment, providing
546 Germeç and Taner American Journal of Orthodontics and Dentofacial Orthopedics
April 2008

Table VIII. Treatment changes in the nonextraction group (n ⫽ 13)

Pretreatment Posttreatment Difference
Mean ⫾ SD Mean ⫾ SD Mean ⫾ SD P

1. FMA (°) 25.9 ⫾ 4.3 25.7 ⫾ 5.0 ⫺0.2 ⫾ 2.1 .656

2. Lower facial height (°) 46.4 ⫾ 2.9 47.0 ⫾ 3.4 0.6 ⫾ 1.2 .065
3. SNA (°) 78.4 ⫾ 3.3 78.5 ⫾ 3.1 0.1 ⫾ 0.5 .453
4. SNB (°) 76.2 ⫾ 2.7 76.3 ⫾ 2.6 0.1 ⫾ 0.6 .426
5. ANB (°) 2.2 ⫾ 1.3 2.2 ⫾ 1.3 0.0 ⫾ 0.5 1.000
6. Pog-NB (mm) 2.5 ⫾ 1.9 2.5 ⫾ 2.0 0.0 ⫾ 0.6 .791
7. U1-SN (°) 103.3 ⫾ 6.5 101.7 ⫾ 5.6 ⫺1.6 ⫾ 3.7 .227
8. U1-NA (°) 24.7 ⫾ 5.6 23.5 ⫾ 5.3 ⫺1.2 ⫾ 3.9 .504
9. U1i-PTV (mm) 58.9 ⫾ 4.9 59.6 ⫾ 4.7 0.7 ⫾ 1.2 .063
10. U6m-PTV (mm) 29.5 ⫾ 3.7 30.2 ⫾ 3.6 0.7 ⫾ 0.5 .004†
11. IMPA (°) 92.9 ⫾ 5.5 94.7 ⫾ 4.5 1.8 ⫾ 3.0 .059
12. L1-NB (°) 24.9 ⫾ 3.3 26.5 ⫾ 2.8 1.6 ⫾ 2.0 .019*
13. L1i-PTV (mm) 55.4 ⫾ 4.3 56.8 ⫾ 4.1 1.4 ⫾ 1.2 .005†
14. L6m-PTV (mm) 30.8 ⫾ 3.6 31.4 ⫾ 3.8 0.7 ⫾ 0.6 .008†
15. Overjet (mm) 3.9 ⫾ 1.3 2.7 ⫾ 0.8 ⫺1.1 ⫾ 0.7 .002†
16. Overbite (mm) 3.3 ⫾ 1.1 2.8 ⫾ 1.00 ⫺0.5 ⫾ 0.9 .053
17. Nasolabial angle (°) 113.1 ⫾ 9.5 110.1 ⫾ 8.4 ⫺3.0 ⫾ 5.0 .039*
18. Maxillary sulcus contour (°) 142.6 ⫾ 11.6 141.5 ⫾ 9.3 ⫺1.1 ⫾ 10.7 .638
19. Mandibular sulcus contour (°) 139.3 ⫾ 11.8 135.4 ⫾ 9.4 ⫺3.9 ⫾ 6.0 .050
20. Pn-PTV (mm) 87.5 ⫾ 5.9 89.2 ⫾ 5.4 1.7 ⫾ 1.5 .007†
21. Sls-PTV (mm) 68.8 ⫾ 4.6 70.1 ⫾ 4.8 1.3 ⫾ 1.1 .005†
22. Ls-PTV (mm) 71.2 ⫾ 4.4 72.9 ⫾ 5.0 1.7 ⫾ 1.3 .002†
23. Li-PTV (mm) 68.7 ⫾ 4.8 70.2 ⫾ 5.3 1.5 ⫾ 1.5 .004†
24. Ils-PTV (mm) 60.5 ⫾ 4.6 61.2 ⫾5.0 0.7 ⫾ 1.5 .133
25. Pog=-PTV (mm) 61.0 ⫾ 6.0 62.2 ⫾ 6.9 1.1 ⫾ 1.6 .035*
26. Superior sulcus depth (mm) 2.5 ⫾ 1.2 3.0 ⫾ 1.1 0.5 ⫾ 0.9 .085
27. Ls-SnPog= (mm) 1.9 ⫾ 1.2 2.4 ⫾ 1.2 0.5 ⫾ 0.9 .058
28. Ls-E-plane (mm) ⫺5.4 ⫾ 1.8 ⫺5.2 ⫾ 1.6 0.2 ⫾ 1.0 .501
29. Ls thickness (mm) 11.0 ⫾ 1.1 12.1 ⫾ 1.8 1.1 ⫾ 1.1 .012*
30. Li-SnPog= (mm) 2.2 ⫾ 1.1 2.9 ⫾ 1.5 0.7 ⫾ 1.1 .046*
31. Li-E-plane (mm) ⫺2.6 ⫾ 1.7 ⫺2.1 ⫾ 1.9 0.5 ⫾ 1.1 .098
32. Li thickness (mm) 14.9 ⫾ 1.9 15.3 ⫾ 2.3 0.4 ⫾ 1.7 .607
33. Inferior sulcus depth (mm) 4.5 ⫾ 1.6 4.8 ⫾ 1.6 0.3 ⫾ 0.4 .052

*P ⬍.05; †P ⬍.01.

evidence for the selection criteria of borderline subjects
with similar characteristics.
In our extraction group, the maxillary and mandibular
incisors were retracted approximately 1.7 mm, and the
maxillary and mandibular molars were moved mesially
approximately 3 mm. The remaining extraction spaces
after the elimination of moderate dental crowding were
closed with reciprocal movements of the anterior and
posterior teeth and without preserving posterior anchor-
age. During consolidation, incisor labial crown torque was
used to increase anterior anchorage against the posterior
teeth, and the anterior segment was tied together. The
posterior segments of the archwire were rounded to
facilitate mesial molar movement. It was stated that labial
crown torque of the incisors decreased the amount of
incisor retraction.27 In accordance with our findings,
Saelens and De Smit14 also reported greater mesial molar
movement than backward incisor movement after 4 first
premolar extractions without extraoral force or intraoral
anchorage control.
In this study, the slight retraction of the incisors did
not cause retrusion of the lips but resulted in increased
lip thickness. This can be explained by the growth in lip
thickness due to relaxation. Ricketts32 noted 1 to 2 mm
of thickening of the lips after slight incisor retraction.
In another study, when the maxillary incisors were
retracted approximately 2 mm, it was suggested that the
increased lip thickness seemed to mask the lip retru-
sion.7 Because of the compensatory effects of the soft
tissues, it was also found that both first and second
premolar extraction spaces could be closed without
affecting the facial profile.33
After extraction therapy, although the lip position did
not significantly change by extraction, the upper and lower
lips appeared slightly retrusive relative to E and Sn-Pog=
plane because of postadolescent growth of the nose and
American Journal of Orthodontics and Dentofacial Orthopedics Germeç and Taner 547
Volume 133, Number 4

Table IX.Comparison of treatment time and treatment by the growth of soft-tissue pogonion and the relative
changes between groups recession of the inferior labial sulcus point.
In the nonextraction group, ARS was applied ac-
Extraction Nonextraction
(n ⫽ 13) (n ⫽ 13) cording to the method of Sheridan25 concerning a
Mean ⫾ SD Mean ⫾ SD P maximum enamel reduction of 0.4 mm from posterior
teeth and 0.25 mm from anterior teeth per side. Max-
Treatment time (mo) 24.8 ⫾ 6.9 17.0 ⫾ 4.6 .004†
1. FMA (°) ⫺0.2 ⫾ 0.8 ⫺0.2 ⫾ 2.1 .716 illary incisor positions and inclinations were not altered
2. Lower facial height (°) ⫺0.1 ⫾ 1.0 0.6 ⫾ 1.2 .125 because the maxillary dental arch crowding with a
3. SNA (°) 0 ⫾ 1.5 0.1 ⫾ 0.5 .494 mean value of 5 mm was solved by posterior and
4. SNB (°) ⫺0.3 ⫾ 1.1 0.1 ⫾ 0.6 .340 anterior ARS. On the other hand, in studies evaluating
5. ANB (°) 0.3 ⫾ 1.3 0.0 ⫾ 0.5 .852
treatment changes in nonextraction patients with less
6. Pog-NB (mm) 0.5 ⫾ 0.8 0.0 ⫾ 0.6 .082
7. U1-SN (°) ⫺5.3 ⫾ 5.9 ⫺1.6 ⫾ 3.7 .089 dental irregularity, the maxillary incisors were pro-
8. U1-NA (°) ⫺5.5 ⫾ 6.5 ⫺1.2 ⫾ 3.9 .076 truded to gain space.14,18 In the mandibular dental arch,
9. U1i-PTV (mm) ⫺1.6 ⫾ 2.4 0.7 ⫾ 1.2 .006† the ARS technique provided 5.1 mm of space, whereas
10. U6-PTV (mm) 3.3 ⫾ 1.6 0.7 ⫾ 0.5 .000‡ mean dental crowding was 5.9 mm. Therefore, only
11. IMPA (°) ⫺6.3 ⫾ 3.8 1.8 ⫾ 3.0 .000‡
86% of the mandibular irregularity was solved by ARS.
12. L1-NB (°) ⫺6.0 ⫾ 3.7 1.6 ⫾ 2.0 .000‡
13. L1i-PTV (mm) ⫺1.9 ⫾ 1.9 1.4 ⫾ 1.2 .000‡ The lesser amount of enamel reduction than the extent
14. L6m-PTV (mm) 3.5 ⫾ 1.5 0.7 ⫾ 0.6 .000‡ of irregularity might be explained by the fact that tooth
15. Overjet (mm) ⫺0.2 ⫾ 1.2 ⫺1.1 ⫾ 0.7 .051 morphology, enamel thickness, and the convexity of
16. Overbite (mm) 0.7 ⫾ 1.7 ⫺0.5 ⫾ 0.9 .053 proximal tooth surface limit the amount of reduction
17. Nasolabial angle (°) 1.4 ⫾ 6.3 ⫺3.0 ⫾ 5.0 .061
during stripping.40,41 To preserve tooth anatomy, ex-
18. Maxillary sulcus
contour (°) ⫺3.6 ⫾ 7.4 ⫺1.1 ⫾ 10.7 .369 cessive reduction of teeth was avoided. The rest of the
19. Mandibular sulcus mandibular irregularity was solved by slight mandibu-
contour (°) ⫺2.5 ⫾ 5.8 ⫺3.9 ⫾ 6.0 .412 lar incisor proclination. Therefore, in patients with
20. Pn-PTV (mm) 1.2 ⫾ 1.3 1.7 ⫾ 1.5 .348 crowding, protrusive profile, thin enamel, and reduced
21. Sls-PTV (mm) 0.0 ⫾ 1.8 1.3 ⫾ 1.1 .034*
proximal tooth convexity, ARS might not be indicated.
22. Ls-PTV (mm) ⫺0.1 ⫾ 2.4 1.7 ⫾ 1.3 .009†
23. Li-PTV (mm) ⫺0.1 ⫾ 2.5 1.5 ⫾ 1.5 .014* When deciding on the treatment approach in borderline
24. Ils-PTV (mm) 0.1 ⫾ 2.1 0.7 ⫾ 1.5 .226 patients, the limitations of ARS should be considered.
25. Pog=-PTV (mm) 2.2 ⫾ 3.4 1.1 ⫾ 1.6 .837 Although studies evaluating the treatment changes
26. Superior sulcus depth of nonextraction therapy with ARS in moderate crowd-
(mm) 0.0 ⫾ 0.9 0.5 ⫾ 0.9 .249
ing are lacking in the literature, the findings of studies
27. Ls-SnPog= (mm) ⫺0.8 ⫾ 1.4 0.5 ⫾ 0.9 .006†
28. Ls-E-plane (mm) ⫺1.0 ⫾ 1.6 0.2 ⫾ 1.0 .023* assessing nonextraction treatment for smaller amounts
29. Ls thickness (mm) 0.9 ⫾ 2.2 1.1 ⫾ 1.1 .642 of crowding showed more pronounced mandibular
30. Li-SnPog (mm) ⫺1.2 ⫾ 1.5 0.7 ⫾ 1.1 .003† incisor proclination compared with our findings.9,14,18
31. Li-E-plane (mm) ⫺1.2 ⫾ 1.4 0.5 ⫾ 1.1 .003† In the nonextraction group, overall facial profile
32. Li thickness (mm) 1.2 ⫾ 1.4 0.4 ⫾ 1.7 .835
assessment showed a slight but significant increase of
33. Inferior sulcus depth
(mm) 0.6 ⫾ 0.6 0.3 ⫾ 0.4 .227 0.7 mm in lower lip to Sn-Pog= plane distance. This
statistically significant but clinically negligible change
*P ⬍.05; P ⬍.01; P ⬍.001.
† ‡
seemed to occur because of slight mandibular incisor
proclination. These minimal changes in the lip position
the chin. This finding is supported by many studies of the nonextraction patients were compensated by the
demonstrating retrusion of the lips caused by progressive postpubertal growth of the soft tissues.
growth of the nose and the chin over time.18,34-39 The evaluation of the nasolabial angle showed great
Our findings concerning lip positions prove that individual variability in the nonextraction group. Similar
extraction therapy does not result in flat profiles when findings were reported by Young and Smith.5 The mean
proper orthodontic mechanics enabling posterior an- change of the nasolabial angle with 3° of decrease was
chorage loss are used. smaller than that in a study evaluating nonextraction
In this study, inferior sulcus depth was found to be treatment.9 The minimal treatment changes in the
slightly increased in accordance with the findings of profiles of the nonextraction patients might be due to
some authors who evaluated soft-tissue changes after our treatment approach, eliminating significant labial
extraction therapy.8,20 Although the positions of the dental movements. In our study, we found that nonex-
lips and the inferior labial sulcus point were not traction therapy with ARS did not cause protrusive
changed, the increase in sulcus depth can be explained profiles and had no adverse effects on facial profiles.
548 Germeç and Taner
The comparison of the groups for dental changes
showed that extraction treatment led to the retraction of
both maxillary and mandibular incisors and more me-
sial movements of the maxillary and mandibular first
molars, whereas nonextraction therapy resulted in
slight protrusion of the mandibular incisors. In accor-
dance with these findings, most studies comparing
extraction and nonextraction treatment changes in Class
I malocclusions found significant differences in incisor
inclinations between groups.9,18,19
The evaluation of lip positions relative to the PTV
line showed that lip positions were maintained in the
extraction group, whereas slight protrusion occurred in
the nonextraction group. When the overall effects of
treatment and the maturational process were assessed
regarding anterior reference planes, the profiles of the
extraction patients were 1 to 1.5 mm more retrusive
compared with the nonextraction patients. Due to the
similar postadolescent growth patterns of the nose and
the chin in both groups, the lip positions that were
maintained in the extraction group appeared slightly
retrusive after extraction therapy, whereas lip protrusion
was compensated in the nonextraction group by continued
soft-tissue growth. These findings indicate that, during
differential diagnosis, the effects of postadolescent growth
and maturation should be considered.
In accordance with our findings, Kocadereli18 also
found that extraction therapy resulted in more retrusive
profiles than nonextraction therapy. On the other hand,
Başçiftçi and Üşümez19 reported that, although incisor
proclination occurred in Class I nonextraction patients,
there were no significant differences between the
groups in their final facial profiles. However, the
authors did not state the initial amount of crowding; this
is thought to be an important factor when investigating
the treatment effects of extraction and nonextraction.
In this study, despite the minimal changes after the
treatments, both groups had well-balanced and desir-
able facial esthetics with all profile measurements
within normal limits. Both extraction and nonextraction
with ARS seem to be effective treatment alternatives
for Class I borderline patients with orthognathic facial
profile and moderate dental crowding. These findings
are limited to borderline subjects with moderate crowd-
ing and orthognathic profile. On the other hand, patients
with protrusive lips might benefit more from extraction
than nonextraction therapy, or a nonextraction treat-
ment approach with protraction of the incisors might
improve facial esthetics more than extraction treatment
for borderline patients with concave profiles and mod-
erate crowding. Ackerman and Proffit42 stated that, in
patients with large nose and chin, protraction of the
incisors is a better treatment choice than retraction. A
American Journal of Orthodontics and Dentofacial Orthopedics
April 2008
patient’s profile is a major factor that should be
considered during treatment planning.
The comparison of treatment times between the
groups showed that nonextraction therapy with ARS
reduced treatment time by 8 months because more time
is required to close the spaces after extraction therapy.
This finding supports the general opinion of Sheri-
dan,25,43 suggesting reduced treatment time by ARS as
an advantage of this approach.
Treatment timing is another important factor that
determines the treatment modality in borderline pa-
tients. For postadolescent borderline patients in the
permanent dentition with moderate crowding and or-
thognathic profile, either extraction or nonextraction
with ARS seems to produce successful results. For
younger borderline patients in the mixed dentition,
other treatment approaches such as preservation of
leeway spaces with expansion might be an alternative
to extraction or nonextraction with ARS therapy.
CONCLUSIONS
1. Both extraction and nonextraction with ARS are
effective treatment alternatives for Class I border-
line patients with good facial profile and moderate
dental crowding.
2. Using minimum anchorage in extraction patients
led to retraction of the incisors and significant
mesial movement of the molars. This slight incisor
retraction did not change the lip positions.
3. In nonextraction patients treated with ARS, maxil-
lary incisor positions were maintained, whereas
slight protrusion of mandibular incisors and the
upper and lower lips occurred. The nasolabial angle
decreased significantly.
4. Due to postadolescent growth of the nose and the
chin, the lips appeared slightly retrusive after ex-
traction therapy, whereas lip protrusion was com-
pensated in the nonextraction group.
5. The main soft-tissue profile differences between the
2 groups were the upper and lower lips that were
retruded 1 to 1.5 mm more retruded in the extrac-
tion patients.
6. Nonextraction therapy with ARS reduced the treat-
ment time by 8 months.
In deciding whether to extract in borderline pa-
tients, the clinician should consider the longer treat-
ment time of extraction therapy, the limitations of ARS
combined with nonextraction treatment (enamel thick-
ness, tooth morphology, convexity of proximal tooth
surfaces), and the additional effects of postadolescent
growth. Although this study helped to clarify the
treatment effects of extraction and nonextraction ther-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 4
apies on dentoskeletal structures and facial profiles of
Class I borderline patients, the stability of the results
should be investigated as another factor of significance.
We think that follow-up evaluations of these subjects
will provide informative data on the stability concerns.
We thank Dr. Murat Demirhanoglu for supplying
the Essix machine and the ARS burs.
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