The influence of extraction and nonextraction

orthodontic treatment on brachyfacial and

dolichofacial growth patterns
Lewis Klapper, DMD, MScD, DSc," Serglo F. Navarro, DDS, MS, b Douglas Bowman, PhD, = and
Bernard Pawlowski, DDS, MS d
Ma)~vood, IIL, and Guadalajara, Mexico

The effects of extraction and nonextraction orthodontic treatment mechanics on patients with
dolichofacial and brachyfacial growth patterns between one and two standard deviations were
studied. Groups underwent treatment of either nonextraction or extraction of four premolars with the
appropriate mechanics for the facial type. Changes in the facial axis and correlation between
maxillary molar movement and facial axis change were measured. A positive correlation was found
between the amount of anteroposterior movement of the upper molar and change inthe facial axis in
brachyfacial and dolichofacial patients undergoing nonextraction treatment. A weak correlation was
foufid in the extraction treatment groups. No statistically significant difference was found in the facial
axis change among any of the groups studied, regardless of facial type or plan of treatment. There
were indications of a more severe opening of the facial.axis (Ba-Na plane to constructed gnathion)
with greater degrees of maxillary molar distal movement in both facial patterns studied. (AM J
ORTHODDENTOFACORTHOP1992;101:425-30.)

T h e concept of the constancy of the facial
pattern of persons during growth was the result of the
growth study by Broadbent. I In 1941 he wrote: "After
the pattern of the face is established at the completion
of the deciduous dentition, it is significant that contrary
to current belief, there is no marked change in the
proportion of the face thereafter. It consists of a more
or less proportionate increase in size." Brodie 2 found
that the N-S-Gn angle was one of the most stable f o r
a person, as well as within the group studied. He also
noted that the upper first molar maintained a constant
relationship to the S-N line once it has reached its an-
tagonist. Brodie observed that the morphogenetie pat-
tern of the head was established by the third month of
postnatal life and did not change thereafter. He studied
growing children between the ages of 6 and 14 years.
Lande 3 studied 34 boys from the ages of 3 to 18 years
and found no change in the behavior of the N-S-Gn
angle from 7 to 18 years of age on average, although
individual variation was seen to occur. He found that
the amount of anteroposterior change at gnathion did
'Associate Professor, Department of Orthodontics, Loyola University School
of Dentistry.
bPrivate practice in Guadalajara, Jalisco, Mexico.
'Professor (retired), Department of Pharmacology and Physiology, Loyola Uni-
versity School of Dentistry.
dClinical Professor, Department of Orthodontics, Loyola University School of
Dentistry.
8/I/27741
not correlate with the original facial pattern and intro-
duced the concept of"facial type" with the use of ceph-
alometric measurements, which included N-S-Pog, FH-
S-Gn, and FH-Go-Gn angles, among others. Lande fur-
ther noted that most of the cases in his study, regardless
of differences in facial type, showed the same general
tendencies in growth behavior. The concept of con-
stancy was further modified by the work of Moore 4 who
studied facial growth of treated and untreated patients
with normal and Class II malocclusions. He observed
changes in the facial axis of persons with growth and
concluded that "individual variation of facial pattern
not constancy is the rule." In the treated cases he doc-
umented distal movement of the maxillary first molars
with cervical headgear and showed changes in the facial
axis with treatment. Moore concluded that orthodontic
treatment can favorably or unfavorably influence the
facial growth pattern.
Previously, Downs s had challenged the concept of
the constancy of facial pattem and documented changes
in the facial axis in treated cases, which were both
favorable and unfavorable. He noted that growth effects
on treatment can be more graphically illustrated by se-
lecting extreme deviations from the mean pattern of
growth. Downs went on to stress the importance of
-growth in treatment considerations.
Ricketts 6"s collected 1000 subjects from his practice
and developed a sophisticated cephalometric analysis

425
426 Klapper et al.
on the basis of the norms from this populat!on. He
refined the idea of facial typing and recommended the
use of .five measurements to describe the basic growth
pattern of a person. These were facial depth, facial axis,
mandibular plane angle, lower facial height, and man-
dibular arc. 9 He noted that the majority of persons grow
along their Y axis, whereas some open and others close
with growth. Ricketts t~ showed cases illustrating the
effects of Class II elastics and cervical headgear on the
gi-owth o f treated patients, He went on to perform a
controlled study of treated and untreated Class II Cases n
and described in detail the interaction of the mechanics
of orthodontic treatment with the facial pattern of the
person. He showed the effects on the facial .axis and
upper molar position of cervical headgear, high-pull
headgear, and Class II elastics. He noted that "improve-
ments in facial angle appeared to be slightly inhibited
by ~ervical headgear but improved by high pull head-
gear . . . . . " I n the Class II group without treatment, the
facial axis opened 0.26 ~ Patients who received treat-
ment with ceryical headgear or Class II elastics showed'
the op~ning of the facial axis by 1~ on average. Different
facial patterns treated with cervical headgear all tended
to open the facial axis. A great difference was seen in
those patients having retrognathic facial patterns
(dolichofacial) and underwent treatment with only Class
II elastics. These opened on average 2 ~ in the facial
axis. The effects of Class I1 elastics was described as
"disastrous" in some of these dolichofaciai cases, open-
ing the facial axis by 2 ~ to 5 ~. After this observation,
Ricketts used high-pull headgear on these cases. Prog-
nathic facial types (brachyfacial) resisted bite Opening
by mandibular rotation. Patients who received treatment
with combined headgear and Class II elastics showed
the opening of the facial axis the same as the controls
(0.3~ Patients who received treatment with high-pull
headgearimproved in their facial axis When they would
have been expected to open unfavorably. Ricketts con-
cluded that the selection of the appliance therapy was
effective in controlling the behavior of the chin and
recommended the use of high-pull and cervical head-
gears with different facial types and the selective use
or avoidance of class Ii elastics with certain facial
types.8
Several investigators subsequently studied the
interactions between growth and" orthodontic treat-
ment. n-~7 They further documented the effects Of ortho-
dontic treatment mechanics on the upper molar position
and the facial axis and confirmed what had been learned
in the earlier studies. Most of these authors '~.'4a6 rec-
ommended that mechanics be varied according tr"lhe
facial growth pattern of the patient to overcome unfa-
Am. J. Orthod. Dentofac. Orthop.
May 1992
vorable changes in the facial axis during treatment.
Through the work of these researchers, it has become
firmly established throughout the orthodontic profes-
sion that these principles are routinely applied in Plan-
ning patient treatment. This is also true among the fac-
ulty Of the Loyola Orthodontic Department where the
research for this paper was conducted.
STATEMENT OF PURPOSE
The purpose of the present study was twofold. First,
t o study the effects of an extraction vei'sus nonextraction
treatment plan and currently accepted edgewise me-
chanics on the facial axis of patients whose growth
patterns represented the extremes of facial type. Sec-
ond, we wished to correlate the amount of molar move-
ment anteriorly and posteriorly that was effected during
treatment with change in the facial axis of the treated
patients.
SUBJECTS AND MATERIALS
Two groups of 30 p;itienis each whose treatment had been
completed9 selected from the files Of the Orthodontic
Deparlment of Loyola University School of Dentistry: All
were white boys between the ages Of 12 to 15 years ~/nd were
treated during a 24- to 30-month period. Nearly all of these
subjects were selected for facial patterns WhiCh were one to
two standard deviations brachyfacial or dolichofacial accord-
ing to the facial iyping method of Ricketts (Table I). Points
and planes used for comparison were taken from the Ricketts'
analysis and are shown in Fig. 1. For purposes 0f comparison,
these groups were further subdivided into extraction of four
premolars (N = 15) and nonextraction (N = 15) treatment.
Comparisons were made between the amounts of facial axis
change and upper molar movement in extraction and nonex-
traction treatment in patient groups of widely divergent facial
types. Similar comparisons were made between extraction
and nonextraction treatment of patient groups with similar
facial types. Correlatio n was performed between molar move-
ment and facial axis change within groups.
All patients were treated with edgewise orthodontic ap-
pliances. The mechanics used were those normally applied
by the faculty supervising the treatment. These are vectorial
mechanics consistent with recommendations cited in the lit-
erature (i.e., cervical headgear and Class 1I elastics in bra-
chyfacial patients; high-pull headgear and avoidance of class
11 elastics in dolichofacial patients).
RESULTS
Molar movement
A positive correlation (significant at P < 0.01) was
found between the amount of anteroposterior movement
of the upper molar and Change in the facial axis in both
brachyfacial (r = 0.73) and dolichofacial (r = 0.78)
patients treated fvithout extraction of teeth. A weak
Voh,me 101 Effects of extraction and nonextraction treatment on growth patterns 427
Number 5

M e a s u r e m e n t s Used

I
I
,, I
t/- I

\ I
\ I
\ I
I
/ \
. /

\ I
I

Fig. 1. Points used specific to Ricketts' analysis: CC, intersection of foramen rotundum to constructed
gnathion with basion-nasion; pterygoid vertical (PtV), line perpendicular to FH through posterior of
pterygoid fossa; ~ Point, constructed center of ramus; DC, center of neck of condyle; 6 to PIV, mea-
surement from posterior of upper molar perpendicular to PtV (used to reference molar movement);
PM, where chin prominence changes contour from concave to convex.

Table I. Method of calculating facial index

Mandibularplane angle FII-MP

Lower facial height ANS-Xi-Pm
Mandibulararc Dc-Xi-Pm
Facial axis Ba Na plane to constructedGn
Facial depth Ht-Na Po
The difference between the patients' values and the normal values were calculated for each of the five measurements,summedand divided
by five to yield a mean value designated"Facial Index."

correlation (not statistically significant at P < 0.05)
was found between the molar movement and facial axis
change in both brachyfacial (r = 0.30) and dolicho-
facial (r = 0.40) types when they underwent premolar
extraction treatment. The amount of upper molar move-
ment did not differ statistically between different facial
types treated with extraction (P < 0.93) or without ex-
traction (P < 0.83). However, in the same facial types
treated with different treatment plans, the molar move-
ment was significantly different (brachyfacial extraction
versus nonextraction P < 0.003; dolichofacial extrac-
lion versus nonextraction P < 0.0003). Results are
shown in Table II.
Facial axis change
There was no statistically significant difference in
facial axis change found in comparisons among all the
groups, whatever the facial type or treatment plan.
DISCUSSION
In-'the population studied, the facial axis change
was held to -4- 1o in more th,'in half the patients despite
428 Klapper et al. Am. J. Orthod. Dentofac. Orthop.
May 1992

Table II. Mean and standard deviation of facial axis and molar movement and correlation values found in
the different experimental groups
Molar
Facial A-ris Change* Movements* Correlation
Classification N x • I SD x • 1 SD Coefficient

Brachyfacial with no 15 -0.12 _ 1.25 1.27 _ 3 . 0 5 m m 0.73t

extractions
Brachyfacial with ex- 15 0.59 • 1.72 4.43 • 2.27mm 0.30w
tractions
Dolichofacial with no 15 -0.82 • 1.94 1.03 - 2.74mm 0.78:~
extractions
Dolichofacial with 15 -0.22 • 1.55 4.50 - 1.67mm 0.40w
exuactions

*(-) = Opened.
( + ) = Closed.
Positive values indicate forward m o v e m e n t .
t P :> 0.05.
~:P --<
I
0.01.
w :P > 0.05.

Table IliA. Summary of dolichofacial nonextraction

Facial ~ris change Upper molar to PTV
(degrees) (ram)

C a s e IlO. Opened [ Closed Start l Final l Change* Facial index

16 5.50 15 10 -5.0 - 1.01

88 3.00 18 15 -3.0 - 1.01
10 3.00 18 15 -3.0 - 1.12
89 0.25 18 17 - 1.0 - 1.63
19 0.50 l0 11 ' + 1.0 - 1.84
34 0.25 15 16 + 1.0 - 1.10
24 2.00 18 20 + 2.0 - 1.02
51 0.75 16 18 + 2.0 - 1.01
43 2.00 17.5 20 +2.5 - 1.01
2 1.50 22 25 + 3.0 - 1.39
25 1.00 9.5 12.5 + 3.0 - 2.02
69 ! .IX) 12 15 +3.0 - 1.01
23 0.25 19 22 + 3.0 - 1.01
32 ! .00 19 22.5 + 3.5 - 1.02
68 0.25 15 18.5 +3.5 - 1.18

*(-) = Posterior m o v e m e n t .
(+) = Anterior m o v e m e n t .

treatment plans that may have been expected to pro-
duce greater closing or opening in these more extreme
facial patterns. The group with the most closed mean
facial axis change was the brachyfacial patients treated
with extraction (+0.59). The group with the most
opened mean facial axis change was the dolichofacial
patients treated with nonextraction mechanics ( - 0 . 8 2 ) .
The fact that the facial axis change showed no statis-
tically significant difference in patients with different
facial patterns treated with extraction or nonextraction
treatment plans and the appropriate mechanics dem-
onstrates that vectorial mechanics recommended in the
literature are indeed effective in controlling the position
of the mandible during orthodontic treatment. The treat-
merit mechanics were seen to have more effect than
facial type on upper molar position. More extreme distal
movement of the upper molars in both dolichofacial
and brachyfacial patients tended to result in more ex-
treme opening of the facial axis in both groups in non-
extraction treatments (Tables IliA and liiB). This is
evident when both groups are rank ordered by the
amount of upper molar anteroposterior movement.
Volume 101 Effects of extraction and nonextraction treatment on growth patterns 429
Number 5

T a b l e IIIB. Summary of brachyfacial nonextraction

Facial a.ris change Upper molar to PTV

(degrees) (rnm)

Case no. Opened I Closed Start Final I Change* Facial index

12 2.00 14.5 10.0 -4.5 1.02

50 2.00 22 18 -4.0 1.54
6 1.00 25.5 25 - 0.5 2.59
39 1.00 17 17 0.0 1.02
66 0.25 15 15 0.0 1.01
22 0.25 17 17 0.0 i .02
48 0.25 22 23 + 1.0 1.39
15 1.50 26 27 + 1.0 1.01
89 1.00 15.5 17 + 1.5 1.85
14 1.75 16 18 +2.0 1.07
29 1.00 l1 14 + 3.0 2.05
64 0.75 15 18 +3.0 l.Ol
53 1.25 18 23 +5.0 l.ll
38 ! .25 12.5 18 +5.5 1.52
63 1.00 18 24 + 6.0 1.69

*(-) = Posterior movement.

(+) = Anterior movement.

Orthodontists should take this into account when p l a n -
ning treatment for their patients. Facial axis opening in
brachyfacial patients may be acceptable or even favor-
able, however, in dolichofacial patients nonextraction
treatment could severely affect the outcome of treatment
both dentally and facially. Upper premolar extractions
should be considered, particularly in dolichofacial pa-
tients who have a full Class II molar relationship.
CONCLUSIONS
Extraction and nonextraction mechanics, as cur-
rently recommended, are effective in controlling the
facial axis of patients with dolichofacial and brachy-
facial patterns of one to two standard deviations from
the mean when applied with the appropriate vectorial
mechanics.
Upper molar movement was correlated with open-
ing or closing of the facial axis in nonextraction treat-
ment in both dolichofacial and brachyfacial patients.
There was a tendency seen for more extreme facial axis
opening in both facial types when the upper molar was
moved distally in the range of 3 to 5 mm. This should
be considered in treatment planning patients. Facial axis
opening may be favorable in brachyfacial patients with
short, lower anterior facial height but quite unfavorable
in dolichofacial patients with long, lower facial height.
Extraction of two maxillary premolars may be a more
manageable treatment plan than nonextraction mechan-
ics when the mandibular arch is well positioned, and
the patient has a full Class II molar relationship.
It is the conventional wisdom of this period of ortho-
dontics that it is desirable to extract teeth in patients
with vertical facial patterns to help control the vertical
dimension. It is further believed that extraction should
be avoided in brachyfacial types to avoid excessive
vertical closure. What this study demonstrates is that,
within a reasonable range, one can treat these cases
with or without extractions, as the malocclusions them-
selves may dictate and still be able to limit unfavorable
changes in the facial axis with appropriate mechanics.
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