123

“EVALUATING CHANGES IN LOWER ANTERIOR FACIAL
HEIGHT TREATED WITH EXTRACTION VERSUS NON-

EXTRACTION FIXED MECHANO THERAPY -A SYSTEMATIC
REVIEW AND META ANALYSIS”
Dissertation submitted
in the partial fulfilment of requirements for the Degree of
MASTER OF DENTAL SURGERY

In the specialty of
ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS

(BRANCH CODE: V)
TEERTHANKER MAHAVEER UNIVERSITY

MORADABAD, UTTAR PRADESH
By
Dr. ATAM DEV JAIN

Under the guidance of
Dr. MANISH GOYAL

Principal & Head
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL
ORTHOPEDICS
TEERTHANKER MAHAVEER DENTAL COLLEGE &
RESEARCH CENTRE, MORADABAD-244001 (U.P.)
2018-2021
CERTIFICATE
TEERTHANKER MAHAVEER DENTAL COLLEGE AND RESEARCH
CENTRE, MORADABAD - 244001 (U.P.)
This is to certify that the dissertation titled “EVALUATING CHANGES IN LOWER

ANTERIOR FACIAL HEIGHT TREATED WITH EXTRACTION VERSUS NON-
EXTRACTION FIXED MECHANO THERAPY -A SYSTEMATIC REVIEW AND
META ANALYSIS” is a bonafide and genuine record of the work done by Dr. Atam
Dev Jain, post graduate student. This dissertation is submitted in partial fulfillment
for the award of degree of Master of Dental Surgery in the subject of Orthodontics
And Dentofacial Orthopedics of Teerthanker Mahaveer University, Moradabad for
session 2018- 2021. It has not been submitted (partially or in full) for the award of
any other degree/course.
Guide
Dr. Manish Goyal

Principal & Head
Department of Orthodontics And
Dentofacial Orthopedics
TMDCRC, Moradabad.
Date:
Place: Moradabad
i
ENDORSEMENT BY THE PRINCIPAL
TEERTHANKER MAHAVEEER DENTAL COLLEGE & RESEARCH
CENTRE, MORADABAD (U.P.)
This is to certify that the dissertation titled “EVALUATING CHANGES IN LOWER
ANTERIOR FACIAL HEIGHT TREATED WITH EXTRACTION VERSUS NON-
EXTRACTION FIXED MECHANO THERAPY -A SYSTEMATIC REVIEW AND
META ANALYSIS” is a bonafide research work carried by Dr. Atam Dev Jain. This
dissertation is submitted in partial fulfillment for the award of degree of Master of
Dental Surgery in the subject of Orthodontics and Dentofacial Orthopedics of
Teerthanker Mahaveer University, Moradabad for session 2018-2021.
Dr. Manish Goyal

Principal
Teerthanker Mahaveer Dental College
& Research Centre, Moradabad
Date:
Place: Moradabad
ii
Acknowledgement
“Teachers are those who use themselves as bridges over which they invite their
students to cross, then having facilitated their crossing, joyfully collapse,
encouraging them to create bridges of their own.”
I shall ever, remain thankfully indebted to all those learned souls, my present
and former teachers, known and unknown hands who directly or indirectly motivated
me to achieve my goal and enlightened me with the touch of their knowledge and
constant encouragement. I feel this is an extremely significant and joyous opportunity
bestowed upon me by the God, to think about and thank all those persons.
With supreme sincerity and deep sense of gratitude, I express deepest gratitude
and appreciation to my Guide; Dr. Manish Goyal, Principal & Head, Department of
Orthodontics and Dentofacial Orthopaedics TMDCRC, for his scholastic guidance,
keen interest, constant critical supervision, excellent cooperation, invaluable counsel,
personalized attention, constructive inputs and the zeal to strive towards excellence that
has been influential in moulding me as a professional and motivating me throughout
and rendering help in completing this library dissertation & without his help and
encouragement this dissertation would not have been written.
I express my gratitude and thanks to, Dr. Mukesh Kumar, Professor, for sharing
his knowledge & invaluable suggestions, personalized attention, for being cooperative
and motivating along with his healthy discussion added considerably to my experience.
I would like to express my gratitude and thanks to Dr. Shaksham Madhok,

Reader, for his invaluable guidance, constant encouragement for navigating me with
his constructive ideas throughout and learned suggestions time to time.
I would like to thank Dr. Shalini Mishra, and Dr. Sumit Kumar Tomar senior
lecturers, for helping me out for guiding me with their immense range of knowledge in
this subject & been an excellent guiding light to me by their valuable suggestions and
enduring support.
This list is incomplete without acknowledging Dr. Shruti Premsagar, who

was the source for the initiation of this thesis as well inspiration for me in my early
iii
days & the one who supported me during the inevitable ups & downs of conducting
my research.
I extend my thanks to my fellow postgraduates Dr. Amandeep Kaur, Dr.

Junaid Khan, Dr. Prateek Bhushan Dixit and Dr. Faraz Hasan; my seniors
Dr.T.Sailesh, Dr.Ashish Kushwah, Dr.Sonika, Dr.Akash Jain Potdar and Dr.Shikha
Rani; my juniors Dr. Kalpit Shaha, Dr. Ekta Yadav, Dr. Madhur Sharma, Dr. Yash
Agarwal, Dr. Abrar, Dr. Surbhi Kaushik, Dr. Parul priya, Dr. Haripriya, and Dr.
Tanisha Singh for their constant encouragement and support.
I am highly obliged and grateful to Dr. Zubair for helping me out while
conducting to research work.
I would also like to thank my friends Dr. Vinay Chandela, Dr. Rahat Saleem
and Dr.Najmus Sahar for their constant encouragement. I thank them for being there
for me not only professionally but also personally.
I wish to express my great love and sincere thanks to my grandparents Late Shri
Sukhvir Singh Jain and Late Shrimati Kunta Devi who have constantly showered me
with their blessings and words of encouragement. Both of them have been my
inspiration and continue to be, in my life. I dedicate my library dissertation work to
them.
I owe my deepest gratitude towards Guru Ji for his eternal support, blessings,
and enlightens the way towards a happy and peaceful life.
It is like a drop in the ocean of words that can never reach its mark to
acknowledge infinite love, blessings, sacrifices and constant encouragement of my
beloved parents Dr. Ravi Prakash Jain and Mrs. Nisha Jain without which I would
not have been what I am today. They receive my deepest gratitude and love for their
dedication and the many years of support during my postgraduate studies that provided
the foundation for this work. I owe them my respect and my soul.
I will also take this opportunity to thank my elder brother Dr. Chaitanya Dev
Jain and my brother in law Dr. Kartikay Jain for their timely help and moral support
throughout this study. My dissertation completion is a step forward and an important
event in my life and from bottom of my heart I thank you.
iv
I am at short of words in thanking my elder sister Dr.Rashmi Jain and my sister in law
Dr.Neelima Jain for their constant encouragement, fortitude and never-ending patience has
been my strength and has helped me throughout the course of this study. They were my
constant philosophical and motivating companion through those times whenever I
needed to resolve my research frustrations. Their love and respect always encouraged
me in writing dissertation.
Above all, I want to show my love towards my nephew Rishabh Dev Jain to
become a bundle of joy and filling our hearts with love and affection.
At last, I would like to thank God Almighty for all his blessings.
I dedicate my dissertation to my loving Parents,
Dr. Ravi Prakash Jain and Mrs. Nisha Jain
Dr.Atam Dev Jain
v
CONTENTS
SL NO TOPIC PAGE NO
1. List of abbreviations vii
2. List of figures viii
3. List of tables ix
4. Abstract x
5. Introduction 1-8
6. Review of Literature 9-18
7. Aims and Objectives 19
8. Materials and Methods 20-25
9. Results 26-38
10. Discussion 39-40
11. Conclusion 41
12. Limitations 42
13. Bibliography 43-52
14. Appendices xi
vi
LIST OF ABBREVIATIONS
SL NO ABBREVIATION FULL FORM

1. ASPS American Society Of Plastic Surgeons
2. CEBM Centre For Evidence Based Medicine
3. RR Risk Ratio
4. LAFH Lower Anterior Facial Height

5. ANS-Me Anterior Nasal Spine To Menton
6. TMJ Temporo-Mandibular Joint
7. TMD Temporo-Mandibular Disorder
8. ROB Risk Of Bias
9. TAFH Total Anterior Facial Height
10. FMA Frankfurt Mandibular Plane Angle
11. N-Me Nasion To Menton
12. CI Confidence Interval
vii
LIST OF FIGURES
FIGURE TITLE PAGE NO

NO
1. hierarchy showing quality of evidence 2
2. Cumulative number of publications about meta-
analysis over time, until 24 may 2020 (results from 3
Medline search using text "meta-analysis")
3. (a): example showing fixed effect model. 5
(b): example showing random effect model. 6
4. funnel plot 7
5. PRISMA flow diagram for identification and
27
retrieval of studies.
6. Risk of bias summery using traffic signal light plot
31
designed via robvis tool for individual study.
7. Risk of bias summery using weighted plot designed
via robvis tool. All studies were given equal weight 32
for qualitative assessment.
8. Meta-analysis and forest plot of included studies for
34
ANS-Me.
36
N-Me.
38
FMA.
viii
LIST OF TABLES
TABLE TITLE PAGE NO

NO
Important differences between fixed effect model
1. 5
and random effect model.
Eligibility criteria for the study
2. 20-21
Detailed search strategy for each database

including keywords, result obtained. (All databases
3. 22
were last searched on 9th July, 2020.)
Study design, intervention and outcome assessment

4. 28-29
of all included studies for qualitative data synthesis.
Summary of risk of bias of included studies using
5. 30-31
ROBINS-I Cochrane collaborated tool.
Statistical outcome summary of ANS-Me for each
6. included study for both qualitative and quantitative 33
analysis.
Statistical outcome summary of N-Me for each
analysis.
Statistical outcome summary of FMA for each
analysis
ix
ABSTRACT
Aim and Objectives: The objective of this study was to evaluate the effects of the
four first premolar extraction compared with a non-extraction treated control group
on the lower anterior facial height.
Methods: Electronic search was conducted on PubMed, Cochrane, Scopus, Lilacs,

Scielo, clinical trials, and opengrey.eu databases; only article published in English
were included. The eligibility criteria were extraction of four first premolars compared
with a non-extraction control group treated with fixed mechanotherapy. ANS-Me
(mm) was taken as the primary outcome; FMA and N-Me were selected as secondary
outcomes. ROBINS-I tool was used for the quality assessment and risk of bias.
Heterogeneity was analyzed using statistical tests including chi-squared based Q
statistic, tau-square, and I-squared statistics. Review Manager was used for
quantitative assessment and meta-analysis.
Results: Five retrospective studies were included for quantitative assessment and 3
were included in the meta-analysis due to certain missing data. Extraction of four first
premolars did not affect both primary and secondary outcomes with P=0.65, P=0.93,
and P=0.91, respectively for ANS-Me, FMA, and N-Me.
Conclusion: This review and meta-analysis concluded that there was no statistically
significant effect of extraction of four first premolar on lower anterior facial height.
Keywords: Systematic review, Meta-analysis, First premolar extraction V/S Non-

extraction, Lower anterior facial height.
x
INTRODUCTION
Introduction
In medical field, some essential question have been repeatedly asked and
studied many times through different strategies and methods to get effectiveness of a
specific intervention. In many circumstances, the outcome of these several specific
intervention studies are unlike and incompatible giving us different results, which
makes the clinical decision more difficult to be make regarding the specific
intervention. But when result of such studies are compiled via a proper procedure i.e.
meta-analysis, provides certain important advantages and disadvantages of that specific
treatment modality.1,2
Meta-analysis provides us coherent plus more effective method of allotting

various applied impediments that beset anyone trying to select a more effective
modality and its efficacy through research and played a great role in evidence based
medicine.
Level of evidence was originally first described by the Canadian Task Force on
the Periodic Health Examination in 19793 and further expanded in an article on levels
of evidence for antithrombotic agents in 1989 by Sackett.4. The hierarchies rank studied
according to the probability of bias and it was noticed that in both systems case series
and expert opinions were placed at lowest level and randomized controlled trails were
at highest position because they are formed to be unbiased and low risk of systematic
error. Afterward, American Society of Plastic Surgeons (ASPS) developed the levels
of evidence for prognosis and levels for treatment developed by the Centre for Evidence
Based Medicine (CEBM)5.
1
Introduction
Figure 1: hierarchy showing quality of evidence
In the present hierarchy of evidence (Figure 1), the clinical evidences are placed
according to the level of freedom from various biases that overwhelmed medical
research and places meta-analyses on the top of this hierarchy making it a trademark.
In contrast, case series and case reports, animal research, laboratory studies contain
little clinical significance when it comes for evidence and hence they are placed at the
bottom of hierarchy.6
2
Introduction
Figure 2: Cumulative number of publications about meta-analysis over time,

until 24 may 2020 (results from Medline search using text "meta-analysis")
In late 1970s, meta-analysis began to appear commonly in the medical literature

and a plethora of meta-analyses have occurred and the progression is exponential over
time (Figure 2) and meta-analyses has been reported most frequently cited form of
clinical research.7,8
In 1904, K. Pearson attempted to collect information extracted from several and

numerous sources9,10 to determine efficacy of a specific immunization vaccine among
soldiers keeping them safe from developing typhoid. Another author, R. A. Fisher,
helped in development of modern statistical science.. During initial 1990s significant
studies from social sciences and medical field11–13 helped in growth of meta-analysis
methodology in various field following twenty years of 1977.14–16
On the other hand, Systematic reviews try to deliver a robust overview of the
effectiveness of an intervention, or of a problem in the field of research and can be
united with quantitative meta-analyses to increase the degree of the outcome across
3
Introduction
selective primary studies and helps in analyzing the causes of variation among studies
outcomes (effect sizes).17 A formal methodological steps are used for the literature
search along with study screening, data withdrawal, coding, statistical analysis (that is,
meta-analysis) and detailed documentation of each step. These steps can be mentioned
in a flow chart that is PRISMA flow diagram (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses).18
In a meta-analysis, each study are used to extract one or more outcome that may
be benefit or harm of a measure in the form of effect sizes quantifying the degree by
which one remedy differs from other for a particular outcome on a same scale. Various
ways are given to measure this effect such as the risk ratio (RR), the mean difference,
the odds ratio, the risk difference and, z transformed correlation coefficient.19–21 These
metrics should be scientifically meaningful, interpretable and comparable, and its
sampling distribution should be known, in order to construct a statistical models
appropriately. These models are divided on the basis of effect size between studies and
are named as “fixed effect model” or “common effect model” and “random effect
model”.13,22
It is assumed that in fixed effect model, the effect size of each study included
are same or fixed or common and if any variation seen between true effect size and
observed effect size is only because of sampling error. While in random effect, true
effect size may differ but it can also be same between studies and might varies and the
cause behind these variation are both sampling variation and between study variations
(population, intervention, duration). Owning of certain common characteristics, these
studies are included to perform meta-analysis under random effect model and a mean
result or effect size is measured and sometime produce same result as of fixed effect
model.22–24 Table 1 shows some differences between these two models, and example of
both the models are shown in Figure 3.
4
Introduction
Fixed effect model Random effect model
Effect size is assumed to be same in all Effect size is assumed to not be same in
studies. all studies.
Consider only sampling variation within Sampling variation within studies and
studies (only one source of variation). between studies.
Studies are consider near cohort in Studies performed on different

nature. population are taken to extract net result.
More powerful and easier if effect size Less powerful.

is same.
Heterogeneity I2 statistic < 50%. Heterogeneity I2 statistic > 50%.
Outcome confidence interval is narrow. Outcome confidence interval is wider.
Give higher weight to larger study. Smaller studies also get importance.
Table 1: important differences between fixed effect model and random effect model.
Figure 3(a): example showing fixed effect model.
5
Introduction
Figure 3(b): example showing random effect model.
A significant difference can be observed between given example of both fixed

effect and random effect models. [Figure 3(a) and Figure 3(b)] Here same data
(fictional) have been used for both the models to evaluate how the primary model
affects the results and following differences can be observed, first, assigned weights to
particular studies is more common in random effect. Second, shorter range of
confidence interval for summary effect under the fixed-effects model. Third, difference
in estimate of the effect size under both two models.
Data of meta-analysis has been traditionally present in form of a graph known

as “forest plot”. (Figure 3) Horizontal line corresponding to each study refers to their
confidence interval centered by a black square demonstrating the weightage of
particular study in the result synthesis. Summery effect size attained through combining
of these studies is presented as a ‘diamond’ at the bottom of plot. Vertical line shows
line of no difference. When summery effect diamond touches the line of no difference
consider as a no significant result.25,26
Both the models can be successfully applied on binary outcomes and continuous
outcome. It is essential to have number of events and sample size per group for binary
outcome and it must contain mean, sample size and standard deviation for continuous
outcome.23,24
6
Introduction
While performing meta-analysis, publication bias is a widespread concern,

because negative finding obtained in a clinical trials are less likely to publish then those
of favoring positive result.27 Funnel plot is an easy method to observe occurrence of
publication bias.28 (Figure 4)
Figure 4: funnel plot
Funnel plot evaluates any probable bias graphically which was improved by
light and pillemer and further detailed reviewed by egger and colleagues.29,30 effect size
correspond to sample size of every study included in meta-analysis are shown in funnel
plot.31 Larger studies tends to show less variability than those of smaller studies, and
graph formed by these kind of studies are commonly inverted funnel in shape and
usually symmetrical. Asymmetric funnel plot believers that meta-analysis might have
overlooked definite trials additionally smaller studies usually display nil effect.29,31–34
To establish a good facial esthetics during orthodontic treatment, profile plays

a key role and facial balance is commonly defined by anterior and posterior facial
height. Usually, anterior facial height is less developed than posterior facial height in
normal growth pattern.35,36 These dimension would demonstrate the changes in
mandibular rotation. It is a challenging decision to make and remains a controversial
topic between well-known orthodontics figures; whether to extract a tooth or not,
especially in border line case. Starting from early 1900’s, Angle suggested that
therapeutic extraction of teeth to achieve ideal dentoskeletal relation was not justified
and opposed by his great professional rival, Calvin Case. The reintroduction of
extraction was occurred in mid-20th century and was at peak around 1960’s; when, a
7
Introduction
student of Angle, Charles Tweed observed relapse in non-extraction treatment and

during the same time period, Begg came into picture and supported extraction treatment
protocol.37–40
Extractions are usually recommended in a patient with crowding, increased

facial height, steep mandibular plane, and in minor dentoskeletal disharmony. To
simply understand this concept, assume that, our dentoskeletal component and posterior
teeth are present in a form of occlusal wedge, and when these teeth move in anterior
direction or in posterior direction will close the bite or open the bite, accordingly.41–43
Thus, it is a belief that extraction of a posterior teeth provide upward and forward
movement of molars which rotate mandible counterclockwise and aids in reducing
lower anterior facial height and close the bite of the patients.41,44–47 Some recently
published studies have demonstrated that extraction of premolars may not reduce lower
anterior facial height48–50and may further increase it.51–53
Some authors also stated that sometimes, extraction of teeth were harmful to the
temporo-mandibular joints. However, some studies also concluded that extraction of
tooth do not improve facial height.47,54,55
Therefore, it is necessary to conduct a highly specific systematic review and

meta-analysis to evaluate these changes, thus, the aim of this study was to evaluate the
effects of first four premolar extractions compared with a non-extraction treated control
group on the lower anterior facial height.
8
REVIEW OF
LITERATURE
Review of Literature
F D Lo, W S Hunter (1982)56 took 93 patients of class II division I malocclusion and

divided them into two groups as 50 treated and 43 untreated. This was a cephlometric
study to access changes in soft tissue profile caused by nasolabial angle. They applied
multiple and single regression analysis and correlation to measure these changes. Study
showed that growth does not influence changes in nasolabial angle. However, there was
increase in nasolabial angle as increase in retraction of maxillary incisors. A positive
significant correlation was found between the angle and lower facial height. No
significant difference was found between extraction and non-extraction treatment in
change of nasolabial angle.
Nigel E. Carter (1988)57 study was aimed to investigate the changes in dentoalveolar
structure occurred in class II div I patients after extraction of four 1st premolars. Two
different appliance (Beg and edgewise) were compared and a control group of untreated
patients were taken. Molar extrusion was noted making an increase in lower anterior
facial height. Posterior height was also increases in edgewise group. He concluded that
Begg appliance was more suitable than edgewise.
B Drobocky, R J Smith (1989)58 they examined soft-tissue profiles in 160 patients

between ages of 10 to 30 years taken randomly from five different sources treated with
extraction of four first premolars and noted that 5.2 degree increase in nasolabial angle
along with reduction of lower and upper lip by 3.6 mm and 3.4 mm from e line,
respectively. They concluded that extraction of four premolars did not cause in a dish
in profile. 90% patients showed improvement in profile.
M Garlington, L R Logan (1990)52 23 patients were selected randomly having

mandibular plane angle more than 38 degree. These patients had enucleation of second
premolars in mixed dentition period. Lower anterior facial height was found statically
decreased when Pre-treatment and post-treatment measures were compared.
J M Battagel , H S Orton (1991)59 this retrospective study selected 90 class III patient
divided in 3 groups to evaluate hard tissue changes. Group 1 consist 32 patient treated
by orthopedic appliance, group 2 had 28 patients treated with extraction and group had
30 patient as control. Skeletal changes were seen only in mandible. There was backward
and downward rotation of mandible increasing in lower anterior facial height. This
change was higher in non-extraction group.
9
K Yamaguchi, R S Nanda (1991)49 this study was conducted to evaluate effect of

extraction and non-extraction method on rotation of mandible. 73 extraction and 48
non-extraction patient were selected with mean age of 12.2 years. On measurement of
pre and post treatment cephalogram, lower anterior facial height was increased and
ramus height was decreased in extraction group and showed retrusion along with
posterior rotation of mandible. Extraction and non-extraction method had significant
effect on LAFH, total facial height and ANB angle.
L Klapper, S F Navarro, D Bowman, B Pawlowski (1992)53 conducted study on

patients with brachyfacial and dolicofacail growth pattern to measure effects of non-
extraction and extraction treatment (four premolar). Facial axis changes and correlation
between axis and molar movement were obtained and concluded that non-extraction
group had significant correlation between axis and molar movement while, extraction
group had weak correlation. Both groups had more axis opening and molar movement
in both growth pattern but no significant difference between groups was found for facial
axis.
D E Paquette, J R Beattie, L E Johnston Jr (1992)60 they checked the effect of

extraction and non-extraction treatment outcomes on 63 Class II div I patients. The
study models, lateral cephalogram were evaluated of 30 non-extraction and 33
extraction subjects. Post treatment records were also taken at an average interval of 14.5
years. Post treatment convexity of profile was fuller by 2mm in non-extraction patients.
Most of skeletal relationship was corrected by growth. Result of study showed no
significant difference found between extraction and non-extraction group in relation to
vertical facial dimension.
A L Chua , J Y Lim, E C Lubit (1993)48 in this study, they examined the effects on
ANS-Me of both methods i.e. extraction and non-extraction. Sample of 174 subjects
were collected and divided them equally between Class I and II malocclusions. Subjects
from same age group were taken, and effect of growth on ANS-Me was controlled using
Michigan Growth Standard. Result outcomes of this study showed that extraction
pattern has no significant effect on change of ANS-Me, while, non-extraction pattern
increases the lower anterior height significantly in both type of malocclusion.
10
S Luppanapornlarp, L E Johnston Jr (19993)61 this was a retrospective study

conducted on 238 class II patients and divided them into three prognostic subgroup:
extraction, non-extraction and borderline group. Clear cut patients were asked for
follow up records including cephalograms. At last, 62 patients in which 33 were
extraction and 29 non-extraction were evaluated. Either treatment modality produces
forward displacement of mandible but more in extraction group. Therefore, this study
was not supportive for extraction therapy in terms of profile and vertical dimension
change.
A R Zaher, S E Bishara, J R Jakobsen (1994)62 post-treatment records of 66 class II

div I patients treated non-extraction were taken to evaluate changes during treatment in
short, average and long facial type. Cast and cephalogram of patients were measured at
pre-treatment, post-treatment and post retention. There was no significant difference in
post treatment changes among these facial type. Females having long face showed
increase in LAFH post-treatment.
J A Staggers (1994)51 during orthodontic treatment, extraction of first premolars may

cause TMJ disorder. To check this validity, pre-treatment and post- treatment records
of 83 class I patients were evaluated and divided into 45 non-extraction and 38 first
premolar extraction group and several vertical cephalometric measurements were
observed. On evaluation, no significant difference was found in vertical dimension
between both groups. Both groups created an increase in vertical dimension
cephalometrically.
J R Beattie, D E Paquette, L E Johnston Jr (1994)63 this was a retrospective

comparative study conducted on 63 class II patients to evaluate extraction effect on
TMJ. These cases were borderline divided into two groups; 33 extraction and 30 non-
extraction and long term follow up were taken. 62 signs and symptoms of muscular
dysfunction were studied and no significant difference were found between both
groups. Hence, it can be concluded that extractions do not cause TMD.
R P McLaughlin, J C Bennett (1995)64 gives a paper on dilemma of extraction and

non-extraction therapy and their relation to TMD because, according to some authors,
extraction of premolars cause decrease in vertical dimension and flatting of face caused
by over retraction of anterior and premature contact between incisors pushes condyle
11
posteriorly affecting TMJ. On the other hand, no great number of literatures were found
concerning this problem in extraction patients.
S E Bishara, D Ortho, J R Jakobsen, D Angelakis (1996)65 patients having class II

div I malocclusion were selected to determine post-treatment changes in male and
female patients treated either extraction or non-extraction method. 44 subjects (21 male,
23 female) treated by extraction of 4 first premolar and 47 subjects (20 males, 27
females) were treated by non-extraction method. They used student t test for statistical
result. Result showed males had larger changes in liner dimension than female in both
the groups.
L A Bravo, J A Canut, A Pascual, B Bravo (1997)66 31 class II patients were selected

to conduct this study. 15 patients was treated non-extraction. 16 patients treated with
extraction of four premolar. Pretreatment and post-treatment radiographs were
evaluated to compare soft and hard tissue changes. This study concluded that a
significant hard tissue difference between groups were limited to a more retrusive
position of incisors and a decrease overbite in extraction group. More retruded lips and
increase in labial sulcus were seen in extraction group.
N A Saelens, A A De Smit (1998)67 aim of this study was to evaluate therapeutic

changes occurred in extraction and non-extraction orthodontically treated cases. Two
extraction groups were taken and one non-extraction group was evaluated. Extraction
group included E4 (four first premolar extraction) and E5 (four second premolar
extraction). All groups were treated with Begg appliance. Pre and post- treatment
cephalogram and dental cast were taken to measure profile changes and inclination of
incisors. Results showed favorable changes in profile among all groups. Molars moved
mesially in all groups, but in extraction group it is at greater extent. PAR index showed
reduction of percentage more than 90%.
I Kocadereli (1999)68 this study was conducted to evaluate vertical variations occurred
in non-Extraction and first premolar extraction orthodontically treated class I patents.
80 patients were divided in 2 equal groups and both pre-treatment and post-treatment
records were taken. 8 angular and 6 liner cephalometric measurements were measured.
This study concluded that there was no significant difference found in vertical
dimension in both extraction and non-extraction groups.
12
H B Ong, M G Woods (2001)69 this study was aimed to determine effect of premolar
extraction on dental arch and to check cephalometric changes. 71 patients, treated with
different extraction protocols were taken, and pre and post records were analyzed.
Results of this study showed a wide range of variance among all the groups.
Faruk Ayhan Basciftci, Serdar Usumez (2003)70 in this study skeletal, dentoalvolar
and profile changes were compared in patients with class I and class II div I maoclusion
treated with either extraction or non-extraction. Study comprised 87 patients record
taken before and after treatment. No significant difference found between any groups.
As a conclusion extraction method produce a slightly dish in profile as more of incisor
retraction was taken place. Some skeletal parameters were changed in class II patients
after treatment in extraction group.
Sandra Márcia Hayasaki, José Fernando Castanha Henriques, Guilherme Janson,

Marcos Roberto de Freitas (2005)71 aim of the study was to evaluate effect of
extraction and non-extraction on LAFH of class I and class II div I malocclusion.
Samples consisted 59 patients divided into 4 groups. Group 1 and 2 consisted class I
premolar extraction and non-extraction cases, respectively. Group 3 and 4 had class II
div I premolar extraction and non-extraction cases, respectively. Results showed no
significant difference among all groups in terms of facial heights.
Tae-Kyung Kim, Jong-Tae Kim, James Mah, Won-Sik Yang, Seung-Hak Baek
(2005)72 this study was performed to investigate effect of molar mesial movement on
vertical facial height on first and second premolar extraction cases to check wedge
effect. 27 patients treated by first premolar extraction (P1) and 27 patients with second
premolar extraction (P2) was taken. Both groups showed increase in anterior facial
height. More of mesial molar movement was taken place in P2 group with less
retraction of both upper and lower incisors. There is no significant difference was found
between both the groups in relation to vertical dimension of face.
Kazem S Al-Nimri (2006)73 study was proposed to compare changes in vertical facial
height in class II div I patients treated extraction of either mandibular first premolars or
mandibular second premolars. Both groups also had extraction of first maxillary
premolars. 26 subjects were considered in both groups. Results indicated that both
groups showed increase in anterior facial height. More of mesial molar movement was
13
taken place in mandibular 2nd premolar extraction group with less retraction of both
upper and lower incisors. This study concluded that extraction of either mandibular
premolars is not aid in counter clock wise rotation of mandible in Class II div I cases.
Mark G Hans et al (2006)74 this study had an objective to evaluate vertical changes
occurred by four premolars extraction and 4 first molar extraction. 31 subjects were
treated by 4 first premolar extraction and 30 patients were treated by 4 first molar
extraction. Control groups were also taken for both the groups matching in age and
genders. Data was analyzed both pre-treatment and post-treatment radiograph. There
was no significant difference in between groups of first molars. In premolar groups, a
clinical significant changes were observed. Both groups showed no increase in
mandibular vertical height.
Aslihan Ertan Erdinc, Ram S Nanda, Tarisai C Dandajena (2007)75 in this study
long term hard and soft tissue effect of orthodontic treatment was compared between 4
premolar extraction and non-extraction group. Radiographic records of 98 patients were
taken and divided equally in both the groups depending upon extraction and non-
extraction pattern. Records were taken at before (T1), after (T2), and 4 years (T3) after
treatment. Results indicated that upper lip position in extraction group was worsen in
T1 and improved lower lip was obtained in non-extraction group after treatment. This
study concluded that there was no significant correlation between soft and hard tissue
at T1, T2, and T3.
Pinar Alkumru, Dilek Erdem, Ayse T Altug-Atac (2007)76 aim was to compare and
evaluate the effect of molar mesialization on vertical facial dimension. Two groups are
formed having 15 patients in each group. First group had four first premolar extractions
in class I malocclusion treated with begg appliance with moderate to maximum
anchorage. Second group has class II patient treated by begg intraoral distalization with
non-extraction. Pre-treatment and post treatment lateral cephalograms were taken. It
was found that there was similar increase in anterior and posterior facial height between
both the groups and concluded that mesial molar movement does not affect vertical
dimension of face.
Guilherme Janson et al (2008)77 the aim of this specific study was to compare
cephalometric changes of class II div I malocclusion treated by two and four premolar
14
extraction and to check post-treatment occlusal success rate. 98 records of patients were
divide into two groups, Group 1 had 55 patients treated by extraction of two maxillary
1st premolars, and Group 2 consisted 43 patients treated by extraction of four 1st
premolars. Pre-treatment and post-treatment casts and radiographs were evaluated.
Results of study showed that group 1 had better occlusal success rate than of group 2.
Group 2 had statistically more vertical facial growth at pretreatment. On conclusion,
both extraction protocol did not influence the success rate of occlusion.
Arunachalam Sivakumar, Ashima Valiathan (2008)78 this study was conducted on

Indian class I subjects treated with extraction and non-extraction aimed to check their
effect on vertical facial height. 31 patients were included in extraction group and 29
patents were included in non-extraction group. Mandibular fiduciary line and FH plane
were used to calibrate cephalograms. Paired and unpaired t tests were used. Results
showed that there were increase in vertical direction in both the group, but greater in
extraction group. Mesial movement of molars were carried out long with extrusion.
Extraction was carried out to increase vertical dimension might not be justifiable.
Mariagrazia Greco, Grazia Fichera, Ersilia Barbato, Rosalia Leonardi (2009)79

purpose of this study was to check the hypothesis that extraction of first premolars leads
to decrease in vertical dimension of face. Study was conducted on pre and post-
treatment records of 28 class I patients treated by extraction of four first premolar. No
statistical difference was found between pre and post-treatment showing no vertical
changes after treatment. Hence null hypothesis was rejected.
Meena Kumari, Mubassar Fida (2010)80 conducted a cross sectional study to

compare dental arch and vertical facial dimension changes occurred after treatment
either with or without extraction. 81 patients were selected, 41 of them were treated
non-extraction and 40 treated by extraction of premolars. Facial height (N-Me), soft
and hard tissue anterior facial height ratio and jarabak ratio were measured to check
vertical dimensions. Results indicated that no significant changes were found in vertical
dimension between both treatment protocols. While intermolar width increased in non-
extraction group.
Guilherme Janson, Tassiana Mesquita Simão, Sérgio Estelita Barros, Marcos

Janson, Marcos Roberto de Freitas (2010)81 conducted study to check cephalometric
15
changes in extraction of 2 maxillary premolars and non-extraction in class II cases on

occlusal success rate. 84 records were identified and divided into two groups. Group 1
had non-extraction treated 31 patients and Group 2 had 53 patients treated by extraction.
This study concluded that both treatment protocols did not affect the occlusal success
rate and vertical dimension.
Çağrı Türköz, Hakan Necip İşcan (2011)82 the aim of this study was to check two
different methods used for evaluation of mandibular rotation in extraction and non-
extraction group due to which results varied. Pre-treatment and post-treatment records
of 70 class I patients were taken and 35 patients were treated by extraction of 4 premolar
and 35 by non-extraction protocol. Pre and post-treatment cephalograms were
superimposed using Steiner’s method and Bjork method. Statistical methods were used
to compare methods. No significant differences were found between both methods. In
both superimpositions, maxilla and mandible moves forward in extraction group and
maxilla moves backward in non-extraction group. Mandible of non-extraction group
shows forward rotation in Bjork and Backward rotation in Steiner’s.
Nikolaos Gkantidis, Demetrios J Halazonetis, Evanggelos Alexandropoulos, Nikos

B Haralabakis (2011)83 this study was aimed to check dilemma between extraction
and non-extraction treatment protocols in hyperdivergent class II division I cases
regarding control in vertical dimension. 57 subjects were taken and divided into two
groups; Group 1, 29 patients treated 4 premolar extraction and high pill headgear;
Group 2 consisted 28 patients treated by non-extraction without any vertical control.
Mesial movement of molars occurred in extraction group but remained same in group
2. Vertical positions of molars in both groups were similar. Vertical variables were also
remained same. Neuromuscular and functional balances are also important for
development of vertical dimension of face.
Chia-Hung Lin, Lesley L Short, David W Banting (2012)84 this present study was
aimed to investigate the effect of non-extraction therapy on patients having
dolichofacial and mesofacial pattern in respect to changes in vertical dimension.
Dolichofacail group consisted 28 patients and mesofacial consisted of 29 patients with
mean ages of 12.3 and 12.6 respectively. Lateral cephalometric radiographs were traced
and menton to ANS, facial axis, facial angle were measured. It was observed that an
16
increase in Me-ANS and facial angle were there. Facial axis remained same during
treatment and 2yr post treatment. This study concluded that vertical dimension of face
is more dependent on genetic factors.
Cui Ye, Xi Du, Qing Zhao, Zhen Tan (2012) 85 subjects between 10-14 years of class
II div I were selected for this study to compare efficiency of 2 phase treatment with
twin block and single phase treatment. 70 patients were put into 2 phase treatment and
76 in single phase. Pre and post-treatment radiographs were evaluated to check changes
in sagittal and vertical dimension. Lower anterior facial height was increased in 2 phase
treatment.
Bajracharya M et al (2013)86 this study had an objective to evaluate the effects of

premolar extraction on anterior lower face height in class II div I patients. 30 patients
were selected with a mean age of 19.4 years and extraction of upper first and lower
second premolar was carried out. No control group was taken. LAHF from ANS to Me
was measure in pre and post treatment radiographs. Result of this study shows that there
is no effect of extraction of premolar on lower anterior facial height.
Marisana Piano Seben, Fabricio Pinelli Valarelli, Karina Maria Salvatore de

Freitas, et al (2013) 87 class II div I were treated orthodontically with 2 maxillary
premolar extraction to evaluate cephalometric changes. 34 patients were considered in
this study and pre and post radiographs were evaluated. Results obtained from this study
showed an increase in LAFH.
Christian Kirschneck, Peter Proff, Claudia Reicheneder, Carsten Lippold (2016)88

this study was based on the belief that extraction of premolars leads to decrease in
vertical dimension. In total, 50 patients were taken of bimaxillary protrusion, of which,
25 had 4 first premolar extraction and 25 had non-extraction treatment as a control.
Results showed that systematic extraction did not influenced vertical and sagittal
dimension. Only slight profile changes were achieved.
Philipp Beit, Dimitrios Konstantonis, Alexandros Papagiannis, Theodore Eliades

(2017)89 this retrospective study was aimed to obtain vertical changes in
morphologically similar patient treated with extraction and without extraction of four
premolars. 83 patients were taken and divided into two groups having 41 patients of
17
extraction of first premolars and 42 patients without extraction. Radiographs were

evaluated digitally. In non-extraction group, N-ANS/N-Me is significantly decreased.
This study concluded that patients treated with extraction showed slight decrease in
vertical dimension of face.
Georgios Kouvelis et al (2018)90 this was a systematic review attempted to evaluate

effect of 4 premolar extraction on vertical height of face. Non-extraction patients were
taken as control group. Several online libraries were searched to the articles. Total of
14 articles were retrieved after application of eligibility criteria. Vertical height
measures were assessed in this review. No meta-analysis was performed. Among all
included measures, only two showed; N-Me and SN-GoGn was found statistically
significant increase in non-extrication group. This review concluded that there is no
effect of extraction on facial vertical height.
18
AIMS AND
OBJECTIVES
Aims and Objectives
AIMS:
The aim of the review and meta-analysis is comparing the pre and post treatment lower
anterior facial height in extraction cases to non-extraction cases in post pubertal age
group.
Objectives:
1) Evaluating the changes in pre and post treatment parameter related to lower anterior
facial height in extraction and non-extraction cases separately.
2) Comparing the changes seen between extractions fixed mechano therapy and non-
extraction fixed mechano therapy.
19
MATERIAL AND
METHODOLOGY
Material and Methodology
Registration and protocol
This systematic review and meta-analysis is conducted according to the Cochrane

Handbook of Systematic Review91 and followed the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) statement.92 Registration of this
review was done under PROSPERO with a registration number CRD42020202472.
Eligibility criteria
The inclusion and exclusion criteria of this review are formed using PICOS approach
(Population, Intervention, Control, Outcome, and study design) and are presented in
Table 2.
Category Inclusion criteria Exclusion criteria
Participants Healthy patients of any gender Non-human subjects

having good oral hygiene,
treated with fixed mechano-
therapy and a mean age of 12
years and above with any type of
Angle’s malocclusion.
Intervention Treatment with Extraction of Patients treated with in
four first premolars. combination of orthognatic
surgery, orthopaedic appliance,
functional appliances and any
other extra appliances
Control Treatment without extraction Patients treated with in
fixed mechano-therapy combination of orthognatic
surgery, orthopaedic appliance,
functional appliances and any
other extra appliances
Outcome Comparison of hard tissue
Lower anterior facial height
measures.
20
Primary outcome- anterior nasal

spine to menton (ANS-Me) in
mm.
Secondary outcome- Frankfurt
mandibular plane angle (FMA)
and total anterior facial height
(N-Me) in mm
Study type Randomized clinical trials, non- Case reports, case series with no
randomized clinical trials, statistical analysis, in-vivo studies
prospective or retrospective and review articles.
studies having a treated and
control groups.
Others Articles published in English Articles published in non-English
language language
Table 2. Eligibility criteria for the study
Information sources and search strategy
Electronic database search was last conducted on 9th July, 2020 with no limitation of
publication year. Several databases was searched during this study which includes:
1. PubMed,
2. Scopus,
3. Cochrane (CENTRAL),
4. Latin American and Caribbean health sciences (lilacs) via Virtual Health
Library (VHL) regional portal, and
5. Scientific electronic library online (scielo).
Additional search for completed, unpublished researches was conducted

electronically through
6. OpenGrey (opengrey.eu) and

7. ClinicalTrials (clinicaltrials.gov) databases.
21
Search engines Key words Res Dup Exclud Exclude Exclude Fin
ult licat ed by d by d by al
studies.
e title abstract full text

PubMed orthodont* AND (extract* OR 547 0 475 26 43 3
nonextract*) AND ("LAFH" OR
vertical OR "lower anterior facial
height" OR "lower anterior vertical
height" OR "inferior anterior facial
height" OR "lower anterior vertical
changes" OR "profile changes" OR
"hard tissue" OR "skeletal height")
Scopus TITLE-ABS-KEY(orthodont* AND 450 320 112 11 7 0
(extract* OR nonextract*) AND "lower
anterior facial height" OR
vertical) AND ( LIMIT-TO (
22
SUBJAREA,"DENT" ) ) AND (
LIMIT-TO ( LANGUAGE,"English" )
Cochrane Same as PubMed 106 35 71 0 0 0
LILACS via VHL Same as PubMed 25 12 7 6 0 0
regional portal
SciELO Same as PubMed 26 23 3 0 0 0
clinicaltrials.gov orthodontic AND extraction | 51 6 45 0 0 0
Completed Studies
Opengrey.eu orthodont* AND extract* lang:"en" 3 0 3 0 0 0
Additional hand 8 0 0 0 6 2
databases. Table 3 consists detailed search strategies for each databases.
searched
Total 121 396 716 43 56 5
6
Table 3. Detailed search strategy for each database including keywords, result obtained. (All databases were last
While creating search strategy, a combination of free text and MeSH (Medical Subject
We also performed hand screening of reference list of relevant articles for additional
Headings) words were used for PubMed and then these words were reformed for every
searched on 9th July, 2020.)

Study selection and data collection
The recognized studies from the databases search were sequentially assessed in two
stages. The title and abstract of studies were screened in the first stage followed by
the second stage in which, the full-text assessment was carried out for final selection
and suitability. This process was performed independently by one author (ADJ) and
in duplicate checked against the criteria by another author (SK). Any conflicts were
resolved by detailed discussion and agreement of a third author (SM). These authors
were not blinded.
Data collection was performed using the same protocol and authors on a customized
data extraction sheet. The extraction sheet included the names of authors, publication
year, study design, details of each extraction group and non-extraction group (the type
of malocclusion, number of participants, mean age, gender, intervention, and duration
of treatment), assessment method, outcome, and magnification control. Numerical
data of included studies were also collected using a customized sheet for both primary
outcome and secondary outcomes, separately. Secondary data were obtained only
from included studies for the primary outcome.
Risk of bias (ROB) in each study and quality measurement
Cochrane risk of bias tool was used to investigate the risk of bias in each study with
help of Risk Of Bias In Non-randomized Studies - of Intervention (ROBINS-I) tool93
specially generated for non-randomized study. ROBINS-I tool evaluates seven
following domains (D) of bias in each study.
1. Bias due to confounding

2. Bias in selection of participants into the study
3. Bias in classification of interventions
4. Bias due to deviations from intended interventions
5. Bias due to missing data
6. Bias in measurement of outcomes
7. Bias in selection of the reported result
23
First two domains are used to assess pre intervention bias. Third domain is applicable
at time of intervention. Rest four domains assess post intervention bias. In addition,
an overall bias assessment is also made in form of critical, serious, moderate and
low.94 Risk‐of‐bias VISualization (robvis)95 tool was used to design traffic signal light
plot and weighted plot for each study included in this review. Data obtained from
ROBINS-I tool was used to design both plots and each study was given equal weight
(1) for weighted plot.
Risk of bias across studies
Assessment of reporting biases across studies were planned for this appraisal but
couldn’t be conducted owing to restricted number of included study.
Standard funnel plot could also be drawn if it includes more than ten studies in the
meta-analysis.
Summary measures and data synthesis
Primary and secondary data of each included study was summarized separately and
found appropriate for data pooling, if identical interventions were compared.
Secondary outcomes were observed only for those studies who had primary outcome.
Studies with either complete or incomplete data-set were included in this analysis
according to need of quantitative and qualitative assessment. In case of missing certain
data, if possible; it was calculated from existing given data or corresponding author
was contacted for further details.
Statistical heterogeneity was evaluated using chi squared based Q statistic for within
study error, tau-squared for absolute heterogeneity, and I-squared statistics for relative
heterogeneity.96 I square statistic was reported to judge heterogeneity as high,
moderate and low corresponding to values of 75%, 50% and 25%, respectively. It is
reported that use of fixed effects model if, I square is <50% and random-effects model
for I square >50%.97
Original data from primary studies were quantified using non-Cochrane review mode
of Review Manager 5.4 (RevMan 5.4; Nordic Cochrane Centre, Cochrane
Collaboration, Copenhagen, Denmark) software. Considering, included studies have
24
several variables like patient’s age, appliance used, gender and operator, a random
effects model was adopted to estimate average distribution. Standard mean difference
(SMD) at 95% confidence interval (CI) was calculated for meta-analysis. In addition
subgroups of class I and class II were also formed in forest plot for both primary and
secondary outcomes.
25
Results
Results
Study selection
Total 1216 records including 396 duplicates were found during literature search;
1204 results were found through database search and 8 were identified by manual
search. A detailed study selection protocol is shown in Figure 5. After conducting stage
one screening of remaining records, 716 records were excluded on the basis of title and
43 records on the basis of abstract. Remaining 61 records then screened for stage two
for full text screening. After application of inclusion and exclusion criteria on full text
reading, only 5 records60,61,68,71,78 were selected for qualitative evaluation, and only 3
articles68,71,78 were considered suitable for quantitative analysis because other two
studies60,61 have missing data (standard deviation).
Study characteristics
Five60,61,68,71,78 retrospective studies were finally included in this systematic

review. (Table 4) Two60,61 out of five studies had lack of potential data so, could not be
included in meta-analysis. All included studies were published in English language.
Standard edge wise appliance was used to treat both extraction and non-extraction
group in all included studies.60,61,68,71,78 Extraction of all four first premolar was carried
in extraction group and compared with treated non-extraction group.
These 5 studies60,61,68,71,78 included a total number of 166 patients in extraction

group and 158 patients in non-extraction group. Male to female ratio was not divided
equally in any of included studies except for one study71 who had considerable same
ratio. Three studies60,68,71 had reporting mean of 12 years in both treatment groups. Age
distribution was not given for one included study61 and one other study78 had mean age
of 17.5 years.
Among all included study, only one study71 had evaluated changes for both
Class I and Class II malocclusion separately. Effects of either treatment on Class I
malocclusion and class II malocclusion was evaluated independently in studies68,78 and
studies60,61, respectively. Average treatment duration was different among all the
studies. Treatment outcomes in all studies60,61,68,71,78 were measured using pre and post
lateral cephalogram and a précised hand tracing was performed to record primary and
secondary outcomes. Most importantly magnification control was achieved by
26
Results
digitization of the tracing to eliminate radiographic enlargement in two studies61,71 and

other two studies had used same radiographic machine and one operator for assessment
to reduce uncertainty.70,78 only one study did not reported any magnification control.60
Figure 5. PRISMA flow diagram for identification and retrieval of studies.
27
Table 4. Study design, intervention and outcome assessment of all included studies for qualitative data synthesis.
General Extraction group (E) Non-extraction group (NE) Assessment

information
Autho Stu Maloccl Partici Me interve Treat Maloccl Partici Me interve Treat Assess Outcom Magnifi
r, dy usion pant an ntion ment usion pant an ntion ment ment e cation
publis desi with age durati with age durati method measure control
hing gn gender on gender on
year
Class I n=15 12. 2.45 Class I n=15 11. 2.01 Either

M=6 27 years M=7 87 years Cephal treatme Digitiza
Hayas Ret F=9 yea Four F=8 yea Non- ometri nt tion of
aki et ros r first r extracti c hand approac tracing
28
al28 pec premol on tracing h does to
(2005 tive Class II n=14 12. ar 2.93 Class II n=15 12. 2.58 not eliminat
) division M=7 28 extracti years division M=8 15 years signific e
I F=7 yea on I F=7 yea antly enlarge
r r affect ment
vertical factor
height
Koca Ret Class I n=40 12. Four NA Class I N=40 12. Non- NA Cephal Signific Same
dereli ros M=17 8± first M=16 3 ± extracti ometri antly radiogra
29
pec F=23 2.4 premol F=24 2.2 on c hand increase phic
(1999 tive yea ar yea tracing d in unit and
) rs extracti rs both one
on groups operator
(Table 4 continued)
Results
Luppa Ret Class II n=33 N Four NA Class II n=29 NA Non- NA Cephal No Digitiza
napor ros M=15 A first M=11 extracti ometri difference tion of
nlap pec F=18 premol F=18 on c hand between tracing
and tive ar tracing both to
Johnst extracti groups elimina
on25 on te
(1993 enlarge
) ment
factor
Paque Ret Class II n=33 12. Four 1.84 Class II n=30 12.60 Non- 1.60 Cephal No NA
tte et ros M=13 53 first years M=19 years extracti years ometri significant
al26 pec F=20 yea premol F=11 on c hand difference
(1992 tive rs ar tracing between
) extracti both
on groups
29
Sivak Ret Class I n=31 17. Four 2.92 Class I n=29 18.48 Non- 1.49 Cephal No Same
umar ros M=5 19 first years M=11 ± extracti years ometri significant radiogr
and pec F=26 ± premol F=18 3.61y on c hand difference aphic
Valiat tive 3.8 ar ears tracing between unit,
han27 9 extracti both one
(2008 yea on groups operato
) rs r and
machin
e
magnifi
cation
factor
Results
Results
Risk of bias within studies
As mentioned earlier, ROB was assessed using the ROBINS-I tool for non-
randomized studies and 7 domains for every included study were assessed. Four studies
were categorized at moderate risk26,27,28,29 and one was at serious risk.25 (Figure 6,
Table 5)
Bias due to confounding was serious in one studies25 due to different group
characteristics but moderate for two studies60,71. Classification of intervention and
selection of reported result biases were at low risk and measurement of outcome bias
was at moderate risk for all included studies60,61,68,71,78 because blinding of the operator
was not possible. A detailed form of risk of bias was shown in table 5, and a traffic
signal light plot and weighted plot for each study were shown in figure 6 and figure 7,
respectively; for evaluation of the risk of bias within included studies.
Study Bias Bias in

Bias Bias due Bias Bias Bias in Overall
due to selectio
in to due to in selecti bias
confo n ofclassif deviatio missi measu on of
undin particip
ication ns from ng remen the
g antsof intended data t of reporte
into the
interv intervent outco d
study
ention ions mes result
s
Hayas Moder Modera Low Low Low Mode Low Moderat
aki et ate te rate e
al28
(2005)
Kocad Low Low Low Low Mode Mode Low Moderat
ereli29 rate rate e
(1999)
Luppa Seriou Low Low Low Mode Mode Low Serious
napor s rate rate
nlap
and
Johnst
on25
(1993)
30
Results
Paquet Moder Low Low No Mode Mode Low Moderat

te et ate informat rate rate e
al26 ion
(1992)
Sivak Moder Modera Low Low Low Mode Low Moderat
umar ate te rate e
and
Valiat
han27
(2008)
Table 5. Summary of risk of bias of included studies using ROBINS-I Cochrane

collaborated tool.
Figure 6. Risk of bias summery using traffic signal light plot designed via robvis tool
for individual study.
31
Results
Note- for each domain, every included study was provided with equal weightage so
that bias due to any domain can be divided and assessed equally
Figure 7. Risk of bias summery using weighted plot designed via robvis tool. All
studies were given equal weight for qualitative assessment.
Results of individual studies and meta-analysis
Statistical result of each included study for both primary and secondary
outcomes were listed in Table 6, Table 7, and Table 8. Extraction of all four first
premolar were carried out in experimental group and relevant changes was compared
with non-extraction group for estimate changes in parameter of lower anterior facial
height.
Primary outcome- lower anterior face height (ANS-Me) in mm.
The effect of extraction and non-extraction on Lower Anterior Face Height

(LAFH) from Anterior Nasal Spine to Menton (ANS-Me) was measured in all five
included studies as primary outcome for qualitative analysis. Two out of 5 included
studies favored statistical changes of LAFH between both groups (P <0.05).60,78
Although three studies estimated that extraction of four first premolar did not have any
effect on LAFH.61,68,71 (P >0.05) (Table 6).
32
Author, Study Type of Primary outcome ANS-Me in mm between post and pre- P-value Significanc
publishing design malocclusio treatment lateral cephalogram (extraction e
year n extraction Non-extraction vs non-
N Mean SD P n Mean SD P extraction)
Hayasaki et Retrospectiv Class I 15 2.45 2.42 M 15 3.30 2.84 M 0.385 NS
al28 (2005) e
Class II 14 2.31 2.34 M 15 3.34 2.05 M 0.217 NS

division I
Kocadereli29 Retrospectiv Class I 40 2.93 3.16 0.000 40 3.78 3.72 0.000 0.234 NS
(1999) e
33
Luppanapornla Retrospectiv Class II 33 5.5 M M 29 6.0 M M >0.05 NS
p and e
Johnston25
(1993)
Paquette et al26 Retrospectiv Class II 33 5.3 M M 30 7.3 M M <0.05 S
(1992) e
Sivakumar and Retrospectiv Class I 31 1.33 1.3 <0.00 31 0.60 1.8 0.09 <0.05 S
Valiathan27 e 1
(2008)
Table 6. Statistical outcome summary of ANS-Me for each included study for both qualitative and quantitative analysis
Results
Results
Figure 8. Meta-analysis and forest plot of included studies for ANS-Me.
Only three studies were included for quantitative analysis (meta-analysis).68,71,78

other two studies were excluded from meta-analysis owning to lack of data.60,61 class I
and class II subgroups were also created in forest plot. The standard mean difference
found by Hayaski et al71 ;for class I cases was -0.31 mm with 95% CI of -1.03 to 0.41,
for class II cases was -0.24 mm with 95%CI of -0.68 to 0.20; by Kocadereli68 was -
0.24 mm with 95% CI of -0.68 to 0.20; and by Sivakumar et al78 was 0.46 mm with
95% CI of -0.05 to 0.96. From these three studies, heterogeneity (I2) of 52% was
reported and over all pooled estimate of -0.10 mm with 95%CI of -0.52 to 0.32
overlapped the vertical line of no difference with P = 0.65 indicated that extraction of
four first premolar do not affect lower anterior face height in regards of ANS to Me.
(Figure 8)
Secondary outcomes
Secondary data was obtained only from included studies assessed for primary
outcome. The effect of extraction and non-extraction on Total Anterior Face Height
(TAFH) from nasion to Menton (N-Me) was measured in all five included studies and
one study71 was excluded for FMA evaluation as it did not reported FMA. Likewise
LAFH, two out of 5 included studies favored statistical changes of TAFH between both
groups (P <0.05)60,78, and three studies estimated that extraction of four first premolar
did not have any effect on TAFH.61,68,71 (P >0.05) (Table 7). FMA had significant
P<0.05 only in one study60, while other three studies61,68,78 show P>0.05. (Table 8)
34
Author, Study Type of secondary outcome N-Me in mm between post and pre- P-value Significanc
publishing design malocclusi treatment lateral cephalogram (extraction e
year on vs non-
extraction Non-extraction
extraction)
n Mean SD P n Mean SD P
Hayasaki et Retrospecti Class I 15 4.52 3.81 M 15 5.97 4.38 M 0.341 NS
al28(2005) ve
Class II 14 4.60 2.90 M 15 5.66 4.29 M 0.445 NS
division I
Kocadereli29 Retrospecti Class I 40 4.67 5.05 0.000 40 5.98 5.14 0.000 0.234 NS
(1999) ve
35
Luppanapornla Retrospecti Class II 33 10.5 M M 29 9.8 M M >0.05 NS
p and ve
Johnston25
(1993)
Paquette et al26 Retrospecti Class II 33 9.7 M M 30 12.3 M M <0.05 S
(1992) ve
Sivakumar and Retrospecti Class I 31 2.35 2.3 <0.00 31 0.90 2.1 <0.05 <0.05 S
Valiathan27 ve 1
(2008)
Table 7. Statistical outcome summary of N-Me for each included study for both qualitative and quantitative analysis.
Results
Results
Figure 9. Meta-analysis and forest plot of included studies for N-Me.
Three studies were included for quantitative analysis (meta-analysis).68,71,78 for

TAFH and only two were included for FMA68,78 other studies were excluded from meta-
analysis for both outcomes owning to lack of data. Class I and class II subgroups were
also created in forest plot for TAFH. The standard mean difference for TAFH found by
Hayaski et al71 ;for class I cases was -0.34 mm with 95% CI of -1.07 to 0.38, for class
II cases was -0.28 mm with 95%CI of -1.01 to 0.45; by Kocadereli68 was -0.25 mm
with 95% CI of -0.69 to 0.19; and by Sivakumar et al78 was 0.65 mm with 95% CI of
0.14 to 1.16. From these three studies, heterogeneity (I2) of 66% was reported and over
all pooled estimate of -0.03 mm with 95%CI of -0.53 to 0.47 overlapped the vertical
line of no difference with P = 0.91 indicated that extraction of four first premolar do
not affect total anterior face height in regards of N to Me. (Figure 9.)
Although, standard mean difference for FMA was found -0.16 mm (95% CI, -
0.59 to 0.28) by Kocadereli68 and 0.23 mm (95% CI, -0.27 to 0.73) by Sivakumar et
al78 with a heterogeneity (I2) of 22% and pooled estimate of 0.02 mm (95% CI, -0.36
to 0.39) overlapping the line of no difference with P = 0.93 indicated that result was
not in favor of either treatment. (Figure 10.)
36
Author, Study Type of Secondary outcome FMA (FH-GoMe) in degree between P-value Significanc
publishing design malocclusi post and pre-treatment lateral cephalogram (extraction e
year on extraction Non-extraction vs non-
N Mean SD P n mean SD P extraction)
Kocadereli29 Retrospectiv Class I 40 -0.38 3.17 0.459 40 0.10 2.96 0.832 0.412 NS
(1999) e
Luppanapornla Retrospectiv Class II 33 -1.9 M M 29 -0.6 M M >0.05 NS

p and e
Johnston25
37
(1993)
Paquette et al26 Retrospectiv Class II 33 -0.3 M M 30 -3.8 M M <0.01 S
(1992) e
Sivakumar and Retrospectiv Class I 31 0.55 1.7 0.08 31 0.12 2.0 0.75 0.98 NS
Valiathan27 e
(2008)
Table 8. Statistical outcome summary of FMA for each included study for both qualitative and quantitative analysis
Results
Results
Figure 10. Meta-analysis and forest plot of included studies for FMA.
38
DISCUSSION
Discussion
Whether the extraction of premolars left any effect on lower anterior facial
height has remained a debatable topic for several authors for many decades. A pearl of
current wisdom has developed that extraction in hyperdivergent patients helps us to
control increasing vertical direction and it should be avoided in hypodivergent patients
to avoid the closure of facial height.46,98
As per our knowledge, this review and meta-analysis were the first to precisely
address the effects of extraction of four first premolar on lower anterior facial height.
However, a systematic review90 on the effect of four premolar extraction and non-
extraction treatment was recently published. Previous review was conducted to check
the effect of four premolar extraction on the vertical dimension, regardless of which
premolar had been extracted. Also, that review had not mentioned any specific
appliance used for treating the subjects; extraoral appliances were also considered. The
search terms for this review were also different from the previous one; this describes
the variances in the numbers of the article retrieved. In our study, we focused only on
subjects treated with fixed mechanotherapy and four first premolar extraction rather
than any other extraction pattern; this explains the differences between inclusion and
exclusion criteria of the studies, making this current review more precise. Unlike
another review, we included articles published only in the English language. Moreover,
the previous review did not conduct any meta-analysis because of their inclusion
criteria and selected studies might produce biased results.
Nevertheless, we retrieved a total number of 1216 articles with our search terms
and ending up with 5 articles60,61,68,71,78 one the basis of the desired primary outcome
for the synthesis of qualitative review and 3 articles 68,71,78 for meta-analysis owing to
lack of respective data. This review summarizes results from retrospective clinical
studies on the effect of the first four premolar extraction on the lower anterior face
height and strictly follows our inclusion and exclusion criteria. The level of evidence
was III, as all included studies were retrospective.
A detailed aspect of the treatment protocol for both extraction and non-
extraction groups were not noted in any of the included studies, only extraction pattern
and appliance used were given. This may produce a certain level of heterogeneity. The
method for evaluating LAFH was almost similar and measured on pre and post-
39
Discussion
treatment lateral cephalograms for all studies. These studies followed their protocol to
control radiographic error; Hayaski et al71 and Luppanapornlap et al61 preferred to
analyze digitized hand tracing with Dentofacial Planner 7.02 software (Dentofacial
Software,Toronto, Ontario, Canada), Kocadereli68 and Sivakumar et al78 used the same
radiographic units and single operator, and no such processes were taken by Paquette
et al60 to control radiographic error.
A meta-analysis of three included studies indicates that extraction of four first

premolar does not have any effect on LAHF, statistically, among all the outcomes with
an effect estimate of -0.10 mm, -0.03 mm, and 0.02 mm for ANS-Me, N-Me, and FMA,
respectively. A similar findings were also reported for secondary outcomes. Although,
a study was done by Shivakumar et al78 do slight favor of non-Extraction group with a
standard mean difference of 0.46 mm (95% CI, -0.05 to 0.96), 0.65 mm (95% CI, 0.14
- 1.16), and 0.23 mm (95% CI, -0.27 to 0.73) corresponding to ANS-Me, N-Me, and
FMA; respectively.
40
CONCLUSION
Conclusion
Existing evidence included in this review, the following conclusion can be

drawn regarding the effect of extraction of four first premolar and non-extraction
protocol on the lower anterior facial height.
1. The meta-analysis of included studies showed that there is no specific effect

of extraction of four first premolar treatment compared with non-extraction
treatment done with fixed mechano therapy on the lower anterior facial height
and its different measures.
2. It is not justified to extract or not to extract four first premolars teeth to control
or reduce anterior facial height.
41
LIMITATIONS
Limitations
Language restriction was applied for this review, studies published in the
English language were included; thus certain evidence might be missing owing to
published in other languages. A detailed treatment protocol was also missing from all
studies (like the amount of crowding, methods of closing space) which could help us
to synthesize a more potent review. Although, secondary outcomes were evaluated
only from studies included in this review and could be separately reviewed as primary
outcomes. Moreover, all included studies are retrospective and are more prone to
different types of biases (especially selection bias). Although, it is difficult to conduct
a prospective study or a randomized control trial for such a treatment protocol. Still,
selection bias will be a limitation and can be minimized by including borderline cases.
More importantly, using a modern digital platform for cephalometric measurement
can be a fortune for further studies.
42
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APPENDIX
Appendix
APPENDIX I
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“EVALUATING CHANGES IN LOWER ANTERIOR FACIAL

HEIGHT TREATED WITH EXTRACTION VERSUS NON-

MASTER OF DENTAL SURGERY

ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS

TEERTHANKER MAHAVEER UNIVERSITY

Dr. ATAM DEV JAIN

Dr. MANISH GOYAL

This is to certify that the dissertation titled “EVALUATING CHANGES IN LOWER

Dr. Manish Goyal

This is to certify that the dissertation titled “EVALUATING CHANGES IN LOWER

ANTERIOR FACIAL HEIGHT TREATED WITH EXTRACTION VERSUS NON-

EXTRACTION FIXED MECHANO THERAPY -A SYSTEMATIC REVIEW AND

dissertation is submitted in partial fulfillment for the award of degree of Master of

Dental Surgery in the subject of Orthodontics and Dentofacial Orthopedics of

Teerthanker Mahaveer University, Moradabad for session 2018-2021.

Dr. Manish Goyal

I would like to express my gratitude and thanks to Dr. Shaksham Madhok,

This list is incomplete without acknowledging Dr. Shruti Premsagar, who

I extend my thanks to my fellow postgraduates Dr. Amandeep Kaur, Dr.

I dedicate my dissertation to my loving Parents,

Dr. Ravi Prakash Jain and Mrs. Nisha Jain

Dr.Atam Dev Jain

2. List of figures viii

6. Review of Literature 9-18

7. Aims and Objectives 19

8. Materials and Methods 20-25

10. Discussion 39-40

13. Bibliography 43-52

SL NO ABBREVIATION FULL FORM

4. LAFH Lower Anterior Facial Height

12. CI Confidence Interval

FIGURE TITLE PAGE NO

TABLE TITLE PAGE NO

Detailed search strategy for each database

Study design, intervention and outcome assessment

Methods: Electronic search was conducted on PubMed, Cochrane, Scopus, Lilacs,

Keywords: Systematic review, Meta-analysis, First premolar extraction V/S Non-

Meta-analysis provides us coherent plus more effective method of allotting

Figure 1: hierarchy showing quality of evidence

Figure 2: Cumulative number of publications about meta-analysis over time,

In late 1970s, meta-analysis began to appear commonly in the medical literature

In 1904, K. Pearson attempted to collect information extracted from several and

Fixed effect model Random effect model

Studies are consider near cohort in Studies performed on different

More powerful and easier if effect size Less powerful.

Heterogeneity I2 statistic < 50%. Heterogeneity I2 statistic > 50%.

Outcome confidence interval is narrow. Outcome confidence interval is wider.

Figure 3(a): example showing fixed effect model.

Figure 3(b): example showing random effect model.

A significant difference can be observed between given example of both fixed

Data of meta-analysis has been traditionally present in form of a graph known

While performing meta-analysis, publication bias is a widespread concern,

Figure 4: funnel plot

To establish a good facial esthetics during orthodontic treatment, profile plays

student of Angle, Charles Tweed observed relapse in non-extraction treatment and

Extractions are usually recommended in a patient with crowding, increased

Therefore, it is necessary to conduct a highly specific systematic review and

F D Lo, W S Hunter (1982)56 took 93 patients of class II division I malocclusion and

B Drobocky, R J Smith (1989)58 they examined soft-tissue profiles in 160 patients

M Garlington, L R Logan (1990)52 23 patients were selected randomly having

K Yamaguchi, R S Nanda (1991)49 this study was conducted to evaluate effect of

L Klapper, S F Navarro, D Bowman, B Pawlowski (1992)53 conducted study on

D E Paquette, J R Beattie, L E Johnston Jr (1992)60 they checked the effect of

S Luppanapornlarp, L E Johnston Jr (19993)61 this was a retrospective study