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A LONGITUDINAL CEPHALOMETRIC STUDY OF THE SOFT TISSUE
PROFILE OF MALE AND FEMALE ORTHODONTICALLY
TREATED CLASS I AND CLASS II
SUBJECTS
Katherine G. Barnette, D.M.D.
An Abstract Presented to the Faculty of the Graduate School
of Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2008
ABSTRACT
Many investigators have identified and described the
relationships between growth and orthodontic treatment, and
their effects on the profile. However, there are few
studies that quantitatively evaluate the soft tissue
profile following orthodontic treatment on a long-term
basis, especially into adulthood. The purpose of this study
is to determine if orthodontic treatment has a long-term
effect on the soft-tissue profile, or if treatment produces
a transient effect. Lateral cephalometric radiographs from
a sample of 48 subjects were obtained from a single
orthodontist. The sample consisted of 24 females and 24
males. Half of the sample was treated with extraction of
some combination of first or second premolars and half were
treated non-extraction. The subjects were divided equally
between Class I and Class II malocclusions. Twenty-six
anatomic landmarks were identified to create 30
measurements for evaluation at three time periods: pretreatment (T1, x age=13.4 years), post-treatment (T2,
x age=16.3 years), and long-term (T3, x age=35.0 years).
Positional relationships of the nose, lips, and chin varied
significantly between the groups across all ages. Sexual
dimorphism was evident at all time periods with males
1
outgrowing females. No significant differences were found
between Class I and Class II individuals, however, many
differences were observed when comparing the extraction and
the non-extraction groups. Over the long-term, subjects
treated without extraction had soft-tissue profiles located
more anterior than those treated with extractions.
Understanding how the soft-tissue profile reacts to
orthodontic treatment will help clinicians decide on the
best long-term treatment plan for their patients.
2
A LONGITUDINAL CEPHALOMETRIC STUDY OF THE SOFT TISSUE
PROFILE OF MALE AND FEMALE ORTHODONTICALLY
TREATED CLASS I AND CLASS II
SUBJECTS
Katherine G. Barnette, D.M.D.
A Thesis Presented to the Faculty of the Graduate School
of Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2008
COMMITTEE IN CHARGE OF CANDIDACY:
Professor Rolf Behrents,
Chairperson and Advisor
Assistant Professor Ki Beom Kim
Assistant Clinical Professor Donald Oliver
i
DEDICATION
To my husband, Alan, whose love and friendship make
anything possible.
To my parents, Ken and Sherry, whose love and constant
support have made my pursuit of knowledge possible.
Everything I have ever accomplished has been, in part, due
to your commitment to me.
To my sisters, Sue and Liz, who have always believed in
me. Your help and encouragement have never waivered, thank
you.
To my daughter, Eliza, whose curiosity and
unconditional love bring me more joy than I could have ever
imagined.
ii
ACKNOWLEDGEMENTS
Thank you to Dr. Behrents for guiding me through
this thesis process and helping me learn how to think.
Without his guidance this would not have been possible.
Thank you to Dr. Oliver for his attention to detail and
helping me muddle through the paperwork.
Thank you to Dr. Kim for his support throughout this
process.
iii
TABLE OF CONTENTS
List of Tables. . . . . . . . . . . . . . . . . . . . . . .v
List of Figures. . . . . . . . . . . . . . . . . . . . . .vi
CHAPTER 1: INTRODUCTION
Description of the Problem. . . . . . . . . . . . 1
CHAPTER 2: REVIEW OF THE LITERATURE
History. . . . . . . . . . . . . . . . . . . . . .3
Soft Tissue Analysis. . . . . . . . . . . . . . . 4
Growth Studies. . . . . . . . . . . . . . . . . . 8
Adolescent Changes. . . . . . . . . . . . . 8
Adult Changes. . . . . . . . . . . . . . . 14
Treatment Changes. . . . . . . . . . . . . . . . 20
Purpose. . . . . . . . . . . . . . . . . . . . . 29
References. . . . . . . . . . . . . . . . . . . .30
CHAPTER 3: JOURNAL ARTICLE
Abstract. . . . . . . . . . . . . . . . . . . . .34
Literature Review. . . . . . . . . . . . . . . . 36
Materials and Methods. . . . . . . . . . . . . . 38
Treated Sample. . . . . . . . . . . . . . .38
Analysis. . . . . . . . . . . . . . . . . .39
Untreated Sample. . . . . . . . . . . . . .41
Results. . . . . . . . . . . . . . . . . . . . . 43
Discussion. . . . . . . . . . . . . . . . . . . .57
Gender. . . . . . . . . . . . . . . . . . .58
Angle Classification. . . . . . . . . . . .58
Conclusions. . . . . . . . . . . . . . . . . . . 77
Acknowledgements. . . . . . . . . . . . . . . . .80
Literature Cited. . . . . . . . . . . . . . . . .81
Appendix A. . . . . . . . . . . . . . . . . . . . . . . . 85
Vita Auctoris. . . . . . . . . . . . . . . . . . . . . . .93
iv
LIST OF TABLES
Table 3.1:
Comparison of Males and Females at T1. . . . .44
Table 3.2:
Comparison of Males and Females at T2. . . . .45
Table 3.3:
Comparison of Males and Females at T3. . . . .47
Table 3.4:
Comparison of Class I and Class II at T1. . . 49
Table 3.5:
Comparison of Class I and Class II at T2. . . 50
Table 3.6:
Comparison of Class I and Class II at T3. . . 51
Table 3.7:
Comparison of Extraction and Non-extraction
at T1. . . . . . . . . . . . . . . . . . . . .53
Table 3.8:
Comparison of Extraction and Non-extraction
at T2. . . . . . . . . . . . . . . . . . . . .54
Table 3.9:
Comparison of Extraction and Non-extraction
at T3. . . . . . . . . . . . . . . . . . . . .56
Table A.1:
Comparison of Males and Females at T129 . . . .85
Table A.2:
Comparison of Males and Females at T229 . . . .86
Table A.3:
Comparison of Males and Females at T329 . . . .87
Table A.4:
Comparison of Males and Females at T429 . . . .88
Table A.5:
Comparison of Class I and Class II at T129 . . 89
Table A.6:
Comparison of Class I and Class II at T229 . . 90
Table A.7:
Comparison of Class I and Class II at T329 . . 91
Table A.8:
Comparison of Class I and Class II at T429 . . 92
v
LIST OF FIGURES
Figure 2.1:
Changes of Profile of the Nose from 3 Months
to 18 Years. . . . . . . . . . . . . . . . . 9
Figure 2.2:
Male and Female Nasal Growth Patterns. . . .11
Figure 2.3:
Growth Change at 7, 13, and 18 Years. . . . 12
Figure 2.4:
Late Growth Changes. . . . . . . . . . . . .16
Figure 2.5:
Soft Tissue Outlines for Males and Females. 18
Figure 2.6:
Composite Profiles Illustrating Landmark
Changes by Class and Gender. . . . . . . . .20
Figure 3.1:
Anatomical Landmarks. . . . . . . . . . . . 39
Figure 3.2:
Reference Planes. . . . . . . . . . . . . . 40
Figure 3.3:
Composite Profiles of Treated Subjects
Illustrating Landmark Changes by Gender and
Class. . . . . . . . . . . . . . . . . . . .59
Figure 3.4:
Composite Profiles of Treated Subjects
Illustrating Landmark Changes by Treatment
Rendered. . . . . . . . . . . . . . . . . . 60
Figure 3.5:
Composite Profiles of Untreated Subjects
Illustrating Landmark Changes by Gender and
Class. . . . . . . . . . . . . . . . . . . .61
Figure 3.6:
Composite Profiles Illustrating Landmark
Changes in Treated Subjects: Female, Male,
Class I, and Class II. . . . . . . . . . . .64
Figure 3.7:
Composite Profiles Illustrating Landmark
Changes in Untreated Subjects: Female, Male
Class I, and Class II. . . . . . . . . . . .65
Figure 3.8:
Composite Profiles of Females Illustrating
Landmark Changes Based on Angle
Classification, Gender, and Treatment
Rendered. . . . . . . . . . . . . . . . . . 70
Figure 3.9:
Composite Profiles of Males Illustrating
vi
Landmark Changes Based on Angle
Classification, Gender, and Treatment
Rendered. . . . . . . . . . . . . . . . . . 73
vii
CHAPTER 1: INTRODUCTION
Description of the Problem
In today’s esthetically-driven society, facial
appearance is of considerable importance. With the
popularity of “arch-development” treatments, the concept of
a broader smile and fuller lips is at the forefront in
orthodontics. Due to the increasing scrutiny placed upon
the facial appearance at the completion of orthodontic
treatment, a great deal of research has been conducted to
determine what factors contribute to facial esthetics
naturally (through growth) and through treatment.
Consequently, the assessment of the soft tissue profile is
an important part of orthodontic diagnosis and treatment
planning. A thorough understanding of how orthodontics
effects both the development and maintenance of the soft
tissue profile into adulthood is considered fundamental to
delivering optimum patient care.
There are numerous studies that demonstrate that the
soft tissue profile continues to change throughout life
from childhood into adulthood. Many investigators have
identified and described the relationships between
orthodontic treatment, growth, and their effect on the
profile. However, there are few studies that quantitatively
evaluate the soft tissue profile following orthodontic
1
treatment long term, into adulthood. In order to determine
if orthodontic treatment has an effect on the soft tissue
profile, and whether it is long-term, it would be
beneficial to evaluate the soft tissue changes of treated
patients into adulthood. This study will evaluate the soft
tissue profile at three time periods: pre-treatment, posttreatment, and at a mature age. The focus will be to assess
the profiles of orthodontically treated patients and
determine the differences between Class I and Class II
skeletal patterns, extraction and non-extraction
treatments, and between males and females.
The soft tissue
changes seen in treated individuals will also be contrasted
with the changes seen in untreated individuals.
2
CHAPTER 2: REVIEW OF THE LITERATURE
History
Interest in facial esthetics is not new. As early as
5,000 years ago, the ancient Egyptians recorded their
attitudes on beauty with carvings of Queen Nefertiti. Many
centuries later the Greeks demonstrated their ideals of
beauty with their classic sculptures of the Venus de Milo
and Apollo Belvedere. Subsequently, the Italian sculptor
and painter, Michelangelo, influenced the esthetic
direction of the Renaissance with his sculptures of the
Pieta’ and David.1
Facial esthetics illustrated in classic Greek
sculpture strongly influenced many early orthodontists. In
the late 1800s, Kingsley became interested in tooth
irregularity.2 In the Kingsley paradigm, the articulation of
teeth was secondary to facial esthetics.3 In contrast,
Angle’s perspective in the early twentieth century
emphasized that with ideal occlusion, esthetics will
follow. Even though he referred to the bust of Apollo
Belvedere as having the ideal profile, he felt that a soft
tissue evaluation was not a part of treatment planning.4
Later, partially due to differences in esthetic ideals,
both Tweed and Begg challenged Angle’s non-extraction
philosophy.3 Through his experiences, Tweed developed a
3
concept of normal occlusion that led to facial harmony. In
this regard, he felt that in some cases extraction of teeth
allowed for better esthetics and facial balance. He also
believed orthodontists should place esthetics first on
their list of treatment objectives, allowing for the
improvement of the soft tissue profile.5
Soft Tissue Analysis
Advances in orthodontic technology, especially
cephalometry in 1931,6 led to a shift away from the art of
orthodontic diagnosis and treatment planning as
practitioners relied more on science. Thus, subjective
clinical exams were augmented by quantitative assessments
involving lateral cephalograms and plaster study models.7
Reidel in 1950, stated “there is a need for study of
dentofacial relations, and their effect upon esthetic
balance and facial contours.”8
Around this time, Burstone
also recognized that the soft tissues were an important
consideration in case analysis. In 1958, he developed a
method of profile measurement that could be used to
demonstrate the soft tissue changes incident to orthodontic
treatment. Seven soft tissue landmarks were identified and
used to form a system of angular measurements. In this
scheme, the components were line segments that joined two
soft tissue landmarks. This construction represented a
4
given contour of the face. As the lines that represent
various profile components intersected, contour angles were
formed showing the intricacies of the profile.9
Elaborating on his previous work, in 1959 Burstone
adopted a method of measuring soft tissue landmarks from
adjacent skeletal points relative to common planes. The
horizontal reference plane was the nasal floor and the
vertical reference plane was a line perpendicular to the
nasal floor. Using this assessment, he discovered that
patients with different malocclusions had considerable
differences in their soft tissue configuration. He also
noted that sexual dimorphism was present. For example,
areas inferior to the nose in males had thicker soft
tissue. In addition he found that the total face becomes
less convex with maturation.10
Steiner was also concerned about the facial
appearance. In 1959, he developed a system for evaluating
normal upper and lower incisor position. He offered a
system of “acceptable compromises” that allowed
orthodontists to measure the position of teeth before
treatment in order to create a “good face” after treatment.
In this way, treatment plans could be individualized, with
the overall goal being good facial esthetics.11,12
5
In 1963, Altemus studied the soft tissue profiles of
37 white and 50 black children ages 12-16 years that had
not had any orthodontic intervention. Both groups were
thought to have acceptable facial form. The data showed
that there was a wide range of individual variation of the
soft tissue covering the face, and that there was no
relationship between the soft tissue and the underlying
skeleton.
He believed that consideration should be given
to the soft tissues when treatment planning orthodontic
cases.
Dealing with some of the functional aspects involved
in esthetics, Ricketts developed the “keystone triad.” The
triad consisted of the chin, the lower alveolus, and
environmental considerations.13,14 To extend his concept
further, in 1968, Ricketts formulated the “law of lip
relationship” based on clinical experience. The “E” or
“Esthetic plane” was defined as follows:
In the normal white person at maturity, the lips are
contained within a line from the nose to the chin, the
outlines of the lips are smooth in contour, the upper
lip is slightly posterior to the lower lip when
related to that line, and the mouth can be closed with
no strain.15
Measurement of the upper lip was considered unnecessary
because the curl of the lower lip and its position were
determined by the upper incisors. The upper lip was related
6
to the lower lip, therefore the lower lip became the
reference.
In an attempt to quantify soft tissue relationships,
Holdaway in 1983 created an 11 measurement analysis. The Hline was a direct result of these measurements, and was
defined as a plane from soft tissue pogonion to the tip of
the upper lip. From the H-line the amount of lip protrusion
was measured parallel to Frankfort Horizontal.16 Using this
analysis, Holdaway created a visual treatment objective
(VTO) to aid in treatment planning. He emphasized that the
best possible soft tissue profile should first be
established, followed by tooth movement that will best
develop the patient’s ideal profile.17
In 1986, Park and Burstone challenged the idea that
optimal occlusion and strict adherence to hard tissue
cephalometric standards leads to good facial form. At the
completion of treatment, 30 adolescent patients had lower
incisors positioned 1.5mm anterior to the A-pogonion plane.
A normal sample of patients with excellent profiles was
used for comparison. Post-treatment analysis showed large
variation in excellent profiles with the biggest involving
lip protrusion. They concluded that using a cephalometric
standard based on hard tissues alone would not produce a
7
given profile type, and that facial esthetics requires
consideration of the soft-tissues in treatment planning.18
Further emphasizing the need to consider the soft
tissues during treatment planning, Bergman, in 1999,
created a soft tissue facial analysis. In his analysis, 18
soft tissue traits were assessed, measured, and categorized
according to norms from previous studies. This allowed for
individualized treatment plans to be created by measuring
the soft tissues and balancing the traits with the goal of
improving the esthetic outcome.19
Growth Studies
Adolescent Changes
In an effort to better understand soft tissue profile
changes through time, Subtelny in 1959 evaluated untreated
patients longitudinally. Utilizing the Bolton Growth Study,
30 subjects with serial cephalograms periodically obtained
from 3 months to 18 years were studied. From this sample
tracings were made that included the outline of soft, as
well as hard tissues, for reference. He observed that with
growth, both the skeletal and soft tissue chin moved
downward and forward relative to the cranium. However, the
bony facial profile tended to become less convex with age
and the soft tissue profile increased in convexity. This
showed that the soft tissue changes did not correspond with
8
the underlying skeleton. He also demonstrated that the soft
tissue nose continues to grow downward and forward from 1
to 18 years of age (figure 2.1). This finding further
explains why the soft tissue profile increases in convexity
with age. On the other hand, he found that the upper and
lower lips were closely related to their underlying
skeletal structures. Overall, some areas of the soft tissue
profile followed their underlying skeletal structures
directly, while others did not.20,21
Figure 2.1: Changes of Profile of the Nose from 3 Months to
18 Years (modified from Subtelny).20
Selected areas of the soft tissue profile have been
analyzed independently. Posen, in 1967, used Subtelny’s
sample to study the growth pattern of the nose. He found
that the nose grew downward and anterior, and the soft
tissue profile became more convex between 2 years and 18
9
years of age. Females showed significantly greater degrees
of convexity from the ages of 10 to 17 years.22
Utilizing the Bolton Growth Study, Chaconas23 also
assessed nasal changes with growth in subjects from 10 to
16 years and found similar directional growth as did Posen.
Overall, females demonstrated earlier growth than males and
males demonstrated greater overall incremental growth. It
was also reported that the soft tissue nose grew down and
forward and the nasal bridge elevated. In consideration of
skeletal pattern, Class II subjects had more elevated nasal
bridges than Class I subjects. Also, Class III subjects had
concave noses while Class I subjects had straighter noses.
Chaconas also showed that the convexity of the soft tissue
profile was affected by the anterior position of the nose
and increased with age (figure 2.2).
Meng et al. also evaluated the morphology and position
of the nose through time. Using a constructed
pterygomaxillary vertical plane, he discovered that for
males and females the nose grew more forward than downward.
Also, nose height, depth, and inclination were completed in
females by 16 years, but continued until 18 years in
males(figure 2.3).24
10
Figure 2.2: Male and Female Nasal Growth Patterns. Black
areas indicate 10-13 years of age and gray indicates 13-16
years of age. A. Class I Male; B. Class I Female; C.
Class II Male; D. Class II Female (modified from
Chaconas).23
11
Figure 2.3: Growth Change at 7, 13, and 18 Years. A. Males
B. Females (modified from Meng, et al.).24
12
Another soft tissue growth study was completed by
Nanda, et al. in 1990.25 Longitudinal growth changes of the
soft tissue profile of 40 Caucasian patients between the
ages of 7 and 18 were analyzed. None of the patients had
received orthodontic treatment, and all were considered to
have a balanced facial appearance. The soft tissues were
measured by drawing a reference line from the sphenoethmoid synchondrosis to the pyerygomaxillary point. The
sphenoethmoid synchondrosis was utilized due to its
stability as a landmark after the age of 4 years. They
demonstrated that sexual dimorphism exists in all aspects
of soft tissue thickness, measured at the nose, upper lip,
lower lip, and chin. Females, in general, had a greater
percentage of their adult soft tissue thickness at age 18
years than males.
Genecov, et al. also studied soft tissue development
and found that both males and females show similar amounts
of soft tissue growth from age 7 to age 12 years, but a
dichotomy occurs between the sexes from age 12 to age 17
years. Using a sample from the Bolton Growth Study, they
found that females had concluded a large part of their soft
tissue development by age 12 while males continued to grow
until age 17 years. This led to greater soft tissue
13
dimensions in males, including upper and lower lip
thickness, lower facial height, and nasal projection.26
Hoffelder, et al. in 2007 investigated changes in the
thickness and length of the soft tissue nose, chin, and
upper and lower lips from 6 to 16 years of age. Utilizing
36 subjects with skeletal Class II malocclusions from the
Burlington Growth Study, they found the nose had the
greatest amount of growth. Sexual dimorphism was also
present. Females had thicker noses from ages 9 to 12 years,
however, they were surpassed by males at age 16 years.
Upper and lower lip thickness increased in both males and
females, but it was found that the lower lip thickness and
length are influenced by the position of the upper
incisors. There was also a reduction in facial convexity,
however, the increase in chin prominence was related to
skeletal changes, rather than soft tissue alterations.27
Adult Changes
In a study by Zankl, et al. in 2002, growth charts
were created by using cross-sectional data on 2500 healthy
individuals. Nose length, nasal protrusion, and philtrum
length were measured. As expected, all three tended to be
larger in males than in females. The growth charts also
showed that the nose continues to grow throughout life.28
14
In an adult longitudinal study, Formby studied 24 male
and 23 female Caucasians between the ages of 18 and 42
years. He discovered that the male profile straightened
with age, the lips became more retrusive, and had increased
soft tissue thickness at pogonion. This was in contrast to
females. Their profiles did not become straighter with age,
nor did the lips become more retrusive. In fact, there was
a decrease in soft tissue thickness at pogonion. In both
males and females, the size of the nose increased in all
dimensions, suggesting soft tissue growth continues into
adulthood.29 These findings were in partial agreement with
Forsberg, who in 1979 observed continued forward growth of
the nose. However, he found retrusion of the lips from 24
to 34 years of age in both males and females (figure 2.4).30
15
Figure 2.4: Late Growth Changes (modified from Formby).29
Sarnas and Solow in 1980 studied longitudinal changes
in the facial profile in 151 Caucasian dental students from
the ages of 21 to 26 years. They found that anterior facial
height increased during the 5 year period, especially the
lower facial height. The nose and upper and lower lip
length increased, while upper lip thickness decreased in
males.31
Behrents in 1985 conducted an in-depth longitudinal
study evaluating the aging craniofacial complex. He studied
113 patients from the original Bolton Study who had not had
16
comprehensive orthodontic treatment. He noted that the
changes in soft tissues were greater than osseous changes.
Relative to cranial base structures, soft tissue glabella
and the most anterior point on the nose moved forward and
downward with time. Soft tissue nasion moved in a similar
fashion. Males had larger noses in general. The tip of the
nose moved downward in both sexes, but was less pronounced
in the female. There was no sex difference in the angular
relationship of the anterior nose point to the cranial
base, and subnasale moved down in both sexes. This resulted
in the nose becoming more acutely angled with time, with
females being less acute than males. Stomion, soft tissue B
point, soft tissue pogonion, and the lower lip moved away
from sella and downward from sella-nasion and the anterior
nasal spine. Soft tissue gnathion and menton also followed
similar forward and downward movements. Some subtle
differences between sexes were found in relation to the
soft tissues. Males were found to have a more prominent
pogonion, larger and more prominent lower lips, and a
larger more angled nose. The upper lip in both sexes
flattened and elongated with time. Surprisingly, the
midface seemed to move proportionately downward and forward
with age, as evidenced by stomion holding a constant
17
relationship to the nose. The profile also straightened
over time (figure 2.5).32
Figure 2.5: Soft Tissue Outlines for Males and Females. The
illustration demonstrates profiles at initial and final
ages (modified from Behrents).32
Lemery,33 in 2006 conducted a longitudinal study
comparing soft tissue growth according to gender and Angle
classification. Using a sample of 98 subjects from the
Bolton Growth Study, four age grades were evaluated: 6-10,
12-15, 18-22, and 50-60 years. Soft and hard tissue
18
structures were traced and analyzed. He discovered that
soft tissue changes were greater than hard tissue changes
at the oldest ages. The nose grew downward and forward in
both genders, with more downward growth for males. The
upper lip retruded slightly, while both lips moved
inferiorly. The chin in both males and females grew
downward with males having a more anterior component and
females having a more vertical and posterior component. He
found soft tissue growth differs between Class I and Class
II individuals. At the oldest ages, individuals who
previously had a recessive chin associated with a Class II
profile had landmarks that were more anterior than those
seen in the Class I group. Class II individuals made a
substantial anterior gain, while Class I individuals
maintained their more vertical vector of growth. He noted
that the once mandibular deficient profile surpassed the
Class I profile at some point in young adulthood or later
in life. Lemery concluded that the amount and direction of
soft tissue growth varies with gender, Angle
classification, and time (figure 2.6).
19
Figure 2.6: Composite Profiles Illustrating Landmark
Changes by Class and Gender (modified from Lemery).33
Treatment Changes
Bloom in 1961 evaluated profile changes due to
orthodontic treatment. Sixty orthodontically treated
patients were selected. Half of the subjects were male and
the other half were female. One quarter of the sample had
four premolars extracted. Both hard and soft tissue
landmarks were measured and analyzed. He found that as
teeth were moved with treatment there was a change in the
soft tissue profile around the mouth. As the maxillary
20
incisors changed so did the superior sulcus, upper lip, and
lower lip. As the lower incisors changed so did the
inferior sulcus and lower lip. He found that it was
possible to predict the soft tissue profile changes in
relation to incisor movement using a regression analysis.34
A long-term study evaluating profile changes 10 years
out of retention was performed by Anderson, et al. in 1973.
Seventy patients who had pre-treatment, post-treatment, and
post-retention cephalograms were utilized. The nasionpogonion line and the most labial point of contact of the
lips created an x-y coordinate system for measurements.
Sixteen hard and soft tissue landmarks were recorded and
analyzed. Long-term results showed that the soft tissue
profile flattened, due to nose and chin growth, and the
lips became more retrusive.35 These findings agree with
Rudee,36 who in 1964 assessed profile changes concurrent
with orthodontic therapy. He studied the pre- and posttreatment cephalograms of 85 patients. All linear
measurements were made at right angles to the facial plane
(nasion-pogonion line). He concluded that the average
amount of upper lip retraction is approximately equal to
the average amount of forward movement of the chin, and
only half the average forward growth of the nose.
Therefore, although tooth and lip movements due to
21
orthodontic treatment influence the soft tissue profile,
equal concern should be given to the flattening of the
profile due to growth of the nose and chin.
Hershey in 1972, evaluated profile changes due to
incisor retraction in Class I and Class II female patients.
He evaluated 34 post-adolescent Caucasian females and
measured four hard and four soft tissue landmarks. He found
that movement of the upper incisor showed a moderately
strong correlation with changes in the superior labial
sulcus and labrale superius. As the amount of incisor
retraction increased there was a decrease in prominence of
the lips. However, gross lingual tooth movement may not
result in gross lingual soft-tissue repositioning.
Therefore, incisor retraction produced a reduction in lip
protrusion, but it was unpredictable.37
Garner in 1974, studied soft tissue changes of black
adolescents who underwent orthodontic treatment. The
studied utilized Rudee’s36 design, so all linear
measurements were made at right angles to the facial plane
(nasion-pogonion line). The ratios of tooth change to lipposture change were similar to those reported in Caucasian
samples. There was a 1:1 relationship of lower lip to
mandibular incisor retraction, but a 3.6:1 ratio of
maxillary incisor to upper lip retraction.38
22
Waldman39 in 1982, also evaluated changes in lip
contour with incisor retraction. A reference line, PM, was
constructed by dropping a vertical line from the
intersection of the greater wings of the sphenoid with the
floor of the anterior cranial fossa to the inferior point
of the pterygomaxillary fissure. Lip and tooth retraction,
and axial inclination of the incisors were measured
parallel to the occlusal line, which was constructed
perpendicular to the PM line through the first molars. He
discovered there was no correlation between horizontal
movement of the maxillary incisal edge and change in the
nasolabial angle, but there was a correlation between the
change in angulation of the incisor and the nasolabial
angle. There was a significant correlation between
horizontal retraction of the maxillary incisor and the soft
tissue at labiale superiorus. A more obtuse nasolabial
angle was found with incisor retraction in patients with
steeper palates. Retraction of the maxillary incisors had
less effect on the soft tissue profile than previously
reported by Rudee36 and Garner.38
Drobocky and Smith in 1989 studied profile changes in
160 patients treated with the extraction of four first
premolars. They showed the nasolabial angle increased by
5.2 degrees, and the upper and lower lips retracted 3.4 and
23
3.6mm to the E line, respectively. However, some patients
had more protrusive lips after treatment. They discussed
that the growth of the chin and nose after treatment could
alter profiles long-term, and there is great individual
variability in the effects of treatment. Also, subjective
evaluations of desirable and undesirable profiles often do
not coincide with differences measured cephalometrically.
They concluded that, overall, extractions do not negatively
affect the profile.40
In another study comparing extraction and nonextraction treatments, Paquette et al. recalled 63 patients
14.5 years post-treatment. All patients started with a
Class II, division 1 malocclusion. At the recall
appointment, each patient was shown tracings of their preand post-treatment profiles and was asked to choose the
better looking one. They were unaware it was their own
profile. The results showed that non-extraction treatment
had 2mm more protrusion. Despite the flatter profile, the
extraction patients viewed their orthodontic outcome as
much of an improvement to facial esthetics as their nonextraction cohorts.41
In 1998, Boley et al. studied whether or not general
dentists and orthodontists could distinguish between
extraction and non-extraction soft-tissue profiles post-
24
treatment. Fifty patients’ (25 treated with extractions, 25
treated non-extraction) profile and full-face photographs
were evaluated. The distance from subnasale and the
Holdaway H-line was used to evaluate the fullness of the
lips. They showed that the H values were similar in both
groups and the profiles flattened. Surprisingly, nonextraction patients started with fuller profiles, but
flattened more than the profiles of the extraction
patients. They concluded that it was not possible to
determine from post-treatment photographs whether or not
the patient had extractions.42
In 2000, Bowman and Johnston studied the esthetic
impact of extraction and non-extraction treatment. The
sample consisted of 120 Caucasian patients (70 treated with
extractions, 50 treated non-extraction). Dentists and
laypersons were given pre- and post-treatment profiles to
evaluate for facial esthetics. Both dentists and laypersons
felt that non-extraction treatment had little esthetic
impact, while extractions hurt retrusive profiles and
benefited protrusive profiles. On average, extraction
treatment was considered to be superior if the lower lip
was more protrusive than 3.5mm behind the E plane before
treatment.43
25
Zierhut et al. in 2000 evaluated long-term profile
changes in Class II, division 1 malocclusions. Of the 63
Caucasian patients, 23 were treated with extractions while
40 were treated non-extraction. Long-term results were
reported, on average, 14 years post-retention (mean age
31.6 years). There were no statistically significant
differences between the two groups for the hard and soft
tissue profile measurements. The chin and nose moved
forward relative to the lips in both groups, leading to a
flattening of the profile. Therefore, whether or not
extractions were performed, the long-term profiles were the
same.44
Ramos and de Lima in 2003 evaluated 30 Brazilian Class
II patients and compared them to 30 untreated Class II
individuals from the Burlington Growth Study. Their aim was
to determine if the profiles were different with or without
orthodontic treatment. Both linear and angular measurements
were evaluated, including the angle of convexity (Nasion-A
point-Pogonion). Both groups showed a reduction in the
convexity of the profile, but this reduction was greater in
the orthodontically treated group. The amount of reduction
of convexity in the untreated group was not enough to
correct the Class II malocclusion.45 Bishara found similar
results in 1998.46 In part, he compared treated Class II,
26
division 1 patients to patients with normal Class I
occlusion. He found that in treated patients there was a
significant reduction in the convexity of the profile. This
reduction was significantly greater in the Class II
extraction group than in the non-extraction group.
Wholley and Woods in 2003 studied the effects of
premolar extractions on the curvature of the lips. Two
reference lines were constructed-the pterygomaxillary line
(PM) through sphenoethmoidale and the pterygomaxillary
fissue, and a line perpendicular to PM through
sphenoethmoidale. Both hard and soft tissue landmarks were
located with reference to the PM line. They concluded that
the depths of the lip curves were found to have reduced
after treatment, but there were no differences in the
depths among the different premolar extraction
combinations. Regardless of whether first or second
premolars were extracted, there were minimal changes in
upper or lower lip curvature. The pretreatment thickness of
the upper and lower lips at the level of the vermilion
tissue was the most important pretreatment characteristic
that influenced lip curvature. Therefore, overlying soft
tissues compensate for growth and treatment in any facial
profile.47
27
Stephens, et al. in 2005 studied the long-term profile
changes in extraction and non-extraction patients. Forty
white Class I and Class II patients were evaluated posttreatment and 15 years post-treatment (mean age 29.8
years). They chose a sample that had similar post-treatment
measurements so that any soft tissue profile changes were
attributed to the type of treatment. Three main
measurements were used; two for dental protrusion (U1-SN
and L1-NB), and one for lip protrusion independent of nose
length (Holdaway’s H line). They discovered that in both
groups the lips became more retruded and there was a
decrease in facial convexity, with males showing greater
changes than females. This is due to greater growth of the
male soft tissue nose and chin post-treatment. Most soft
and hard tissue landmarks moved more forward and downward
in males compared to females. There were no differences
between the extraction and non-extraction groups in profile
measurements, as the patients grew similarly during the
post-treatment period. Therefore, long-term post-treatment
changes were not due to the type of treatment rendered.48
28
Purpose
In an effort to determine the effects of orthodontic
treatment on the soft tissue profile, it would be
beneficial to perform a longitudinal study evaluating soft
tissue changes into adulthood. The literature suggests that
growth and treatment affect the profile. Lemery33 showed
changes occur in the untreated soft tissue profile. He
found the amount and direction of soft tissue growth varies
with gender, Angle classification, and time. This study
will rely on Lemery’s research design, but utilize a
treated sample to see if orthodontic treatment affects the
pattern of profile change long-term as compared to normal
growth.
29
References
1. Peck H, Peck S. A concept of facial esthetics. Angle
Orthod 1970;40:284-318.
2. Asbell M., Norman W. Kingsley (1829-1913). Am J Orthod
Dentofacial Orthop 1999;115:101.
3. Sarver D, Ackerman J. Orthodontics about face: The reemergence of the esthetic paradigm. Am J Orthod Dentofacial
Orthop 2000;117:575-576.
4. Angle E. Malocclusion of the Teeth. S.S. White Dental
Manufacturer Company; 1907.
5. Tweed C. Evolutionary trends in orthodontics, past,
present, and future. Am J Orthod 1953;39:81-108.
6. Broadbent B. A new x-ray technique and its application
to orthodontia. Angle Orthod 1931;1:45-66.
7. Sarver D, Ackerman M. Dynamic smile visualization and
quantification: Part 1. Evolution of the concept and
dynamic records for smile capture. Am J Orthod Dentofacial
Orthop 2003;124:4-12.
8. Reidel R. Esthetics, environment, and the law of lip
relation. Angle Orthod 1950;20:168-178.
9. Burstone C. The integumental profile. Am J Orthod
1958;44:1-25.
10. Burstone C. Integumental contour and extension
patterns. Angle Orthod 1959;9:93-104.
11. Steiner C. Cephalometrics in clinical practice. Am J
Orthod 1959;29:8-29.
12. Steiner C. The use of cephalometrics as an aid to
planning and assessing orthodontic treatment. Am J Orthod
1960;46:721-735.
13. Ricketts R. The keystone triad. I. Anatomy,
phlogenetics, and clinical references. Am J Orthod
1964;50:244-264.
30
14. Ricketts R. The keystone triad. II. Growth, treatment,
and clinical significance. Am J Orthod 1964;50:728-750.
15. Ricketts R. Esthetics, environment, and the law of lip
relation. Am J Orthod 1968;54:272-289.
16. Holdaway R. A soft-tissue cephalometric analysis and
its use in orthodontic treatment planning. Part I. Am J
Orthod 1983;84:1-28.
17. Holdaway R. A soft-tissue cephalometric analysis and
its use in orthodontic treatment planning. Part II. Am J
Orthod 1984;85:279-293.
18. Park Y, Burstone C. Soft-tissue profile-fallacies of
hard-tissue standards in treatment planning. Am J Orthod
Dentofacial Orthop 1986;90:52-62.
19. Bergman R. Cephalometric soft tissue facial analysis.
Am J Orthod Dentofacial Orthop 1999;116:373-389.
20. Subtelny J. A longitudinal study of soft tissue facial
structures and their profile characteristics, defined in
relation to underling skeletal structures. Am J Orthod
1959;45:481-507.
21. Subtelny J. The soft tissue profile, growth, and
treatment changes. Angle Orthod 1961;31:105-122.
22. Posen J. A longitudinal study of the growth of the
nose. Am J Orthod 1967;53:746-756.
23. Chaconas S. Prediction of normal soft tissue facial
changes. Angle Orthod 1975;45:12-25.
24. Meng H, Goorhuis J, Kapila S, Nanda R. Growth changes
in the nasal profile from 7 to 18 years of age. Am J Orthod
Dentofacial Orthop 1988;94:317-326.
25. Nanda R, Meng H, Kapila S, Goorhuis J. Growth changes
in the soft tissue facial profile. Angle Orthod
1990;60:177-190.
26. Genecov J, Sinclair P, Dechow P. Development of the
nose and soft tissue profile. Angle Orthod 1990;60:191-198.
31
27. Hoffelder L, de Lima E, Martinelli F, Bolognese A.
Soft-tissue changes during facial growth in skeletal Class
II individuals. Am J Orthod Dentofacial Orthop
2007;131:490-495.
28. Zankl A, Eberle L, Molinari L, Schinzel A. Growth
charts for nose length, nasal protrusion, and philtrum
length from birth to 97 years. Am J Med Genet 2002;111:388391.
29. Formby W. Longitudinal changes in the adult facial
profile. Am J Orthod Dentofacial Orthop 1994;105:464-476.
30. Forsberg C. Longitudinal changes in the adult facial
profile. Eur J Orthod 1979;1:15-23.
31. Sarnas K, Solow B. Early adult changes in the skeletal
and soft-tissue profile. Eur J Orthod 1980;2:1-12.
32. Behrents R. Growth of the Aging, Craniofacial Skeleton
Craniofacial Growth Series. Ann Arbor: Center for Human
Growth and Development: The University of Michigan; 1985.
33. Lemery S. A longitudinal cephalometric study of the
soft tissue profile of male and female Class I and Class II
subjects. St. Louis: St. Louis University; 2006.
34. Bloom L. Perioral profile changes in orthodontic
treatment. Am J Orthod 1961;47:371-379.
35. Anderson J, Joondeph D, Turpin D. A cephalometric study
of profile changes in orthodontically treated cases ten
years out of retention. Angle Orthod 1973;73:324-336.
36. Rudee D. Proportional profile changes concurrent with
orthodontic therapy. Am J Orthod 1964;50:421-434.
37. Hershey H. Incisor tooth retraction and subsequent
profile change in postadolescent female patients. Am J
Orthod 1972;61:45-54.
38. Garner L. Soft-tissue changes concurrent with
orthodontic tooth movement. Am J Orthod 1974;66:367-376.
39. Waldman B. Change in lip contour with maxillary incisor
retraction. Angle Orthod 1982;52:129-134.
32
40. Drobocky O, Smith R. Changes in facial profile during
orthodontic treatment with extraction of four first
premolars. Am J Orthod Dentofacial Orthop 1989;95:220-230.
41. Paquette D, Beattie J, Johnston L. A long-term
comparison of nonextraction and premolar extraction
edgewise therapy in "borderline" Class II patients. Am J
Orthod Dentofacial Orthop 1992;102:1-14.
42. Boley J, Smith S, Fulbright M. Facial changes in
extraction and nonextraction patients. Angle Orthod
1998;68:539-546.
43. Bowman S, Johnston L. The esthetic impact of extraction
and nonextraction treatments on Caucasian patients. Angle
Orthod 2000;70:3-10.
44. Zierhut E, Joondeph D, Artun J, Little R. Long-term
profile changes associated with successfully treated
extraction and nonextraction Class II Division 1
malocclusions. Angle Orthod 2000;70:208-219.
45. Ramos D, de Lima E. A longitudinal evaluation of the
skeletal profile of treated and untreated skeletal Class II
individuals. Angle Orthod 2005;75:47-53.
46. Bishara S. Mandibular changes in persons with untreated
and treated Class II Division 1 malocclusions. Am J Orthod
Dentofacial Orthop 1998;113:661-673.
47. Wholley C, Woods M. The effects of commonly prescribed
premolar extraction sequences on the curvature of the upper
and lower lips. Angle Orthod 2003;73:386-395.
48. Stephens C, Boley J, Behrents R, Alexander R, Buschang
P. Long-term profile changes in extraction and
nonextraction patients. Am J Orthod Dentofacial Orthop
2005;128:450-457.
33
CHAPTER 3: JOURNAL ARTICLE
Abstract
Many investigators have identified and described the
relationships between growth and orthodontic treatment, and
their effects on the profile. However, there are few
studies that quantitatively evaluate the soft tissue
profile following orthodontic treatment on a long-term
basis, especially into adulthood. The purpose of this study
is to determine if orthodontic treatment has an effect on
the soft-tissue profile, or if treatment produces a
transient effect. Lateral cephalometric radiographs from a
sample of 48 subjects were obtained from a single
orthodontist. The sample consisted of 24 females and 24
males. Half of the sample was treated with extraction of
some combination of first or second premolars and half were
treated non-extraction. The subjects were divided equally
between Class I and Class II malocclusions. Twenty-six
anatomic landmarks were identified to create 30
measurements for evaluation at three time periods: pretreatment (T1, x age=13.4 years), post-treatment (T2,
x age=16.3 years), and long-term (T3, x age=35.0 years).
Positional relationships of the nose, lips, and chin varied
significantly between the groups across all ages. Sexual
34
dimorphism was evident at all time periods with males
outgrowing females. No significant differences were found
between Class I and Class II individuals, however, many
differences were observed when comparing the extraction and
the non-extraction groups. Over the long-term, subjects
treated without extraction had soft-tissue profiles located
more anterior than those treated with extractions.
Understanding how the soft-tissue profile reacts to
orthodontic treatment will help clinicians decide on the
best long-term treatment plan for their patients.
35
Literature Review
Interest in facial esthetics is not new. Many early
orthodontists were influenced by classic Greek sculptures
and incorporated their ideas of beauty into orthodontic
treatment planning.1-5 Advances in orthodontic technology,
especially cephalometry in 1931,6 led to a shift away from
the art of orthodontic diagnosis and treatment planning as
practitioners relied more on science. Since that time, many
soft-tissue analyses have been developed in an effort to
describe the craniofacial structures and to create the
ideal treatment plan.7-19 Also, many studies have been
performed in order to better understand how growth and
development affects the skeleton, dentition, and the soft
tissue profile in children and adolescence.20-25 Until
recently, most investigators believed that the skeleton and
soft tissue had completed their growth by age 18. To the
contrary, over the past two decades, investigators have
evaluated the craniofacial complex into adulthood and
concluded that changes do occur into the later decades of
life.26-31 In parallel, many studies have been conducted to
document the interplay between treatment and growth, and
their effect on the profile.32-46 However, there are few
studies that quantitatively evaluate the soft tissue
profile following orthodontic treatment long-term,
36
especially into adulthood. The purpose of this study is to
determine if orthodontic treatment has a long-term effect
on the soft tissue profile, or if the affect of treatment
is transient. The central focus will be to assess the
profiles of orthodontically treated patients and determine
the differences according to Class I and Class II skeletal
patterns, extraction and non-extraction treatments, and
males and females.
The soft tissue changes seen in treated
individuals will also be compared and contrasted with the
changes seen in untreated individuals.
37
Materials and Methods
Treated Sample
A sample of 48 orthodontic patients was selected at
random by arbitrarily entering the files of one experienced
orthodontist and proceeding consecutively until the sample
was complete. It was intended that the sample would consist
of 24 females and 24 males, half were treated with
extractions of four premolars (some combination of first or
second) and half were treated non-extraction, and the
subjects were equally divided between Class I and Class II
malocclusions. High-quality pre-treatment, post-treatment,
and long-term post-retention lateral cephalometric
radiographs with good soft tissue definition were available
for all subjects. Radiographs were taken with the teeth in
occlusion with the lips relaxed.
Consistent treatment objectives were applied to all
patients. The goals of treatment among several were to
establish good occlusion while resolving crowding. The
mandibular incisors were kept in their original position or
uprighted, and the original arch forms were maintained.
Rapid palatal expansion, inter-arch elastics, and headgears
were used determined by the practitioner.
38
Analysis
Following the format established by Lemery,29 26 soft
and hard tissue anatomical landmarks were identified and
traced (Figure 3.1). These landmarks were digitized using a
Numonic digitizing tablet (model # IPS/BL.E-A30BL.H) and
transferred to a computer that translated each landmark
into x-y coordinates. Using Dentofacial Planner 7.0
software, information was translated into the desired
distances and angles.
Figure 3.1:
Anatomical Landmarks
39
Analysis involved the construction of two references
planes. A horizontal reference line was generated at the
level of Nasion equal to the Sella-Nasion reference line
minus 7 degrees and labeled SN-7 (Figure 3.2). A vertical
reference line was constructed perpendicular to SN-7
through Sella. For each landmark, the x-y coordinates were
determined according to the reference planes29.
Figure 3.2:
Reference Planes
40
After the needed distances and angles were derived
statistical analysis was performed using SPSS (Statistical
Package for the Social Sciences) version 14.0.2, (SPSS
Inc., Chicago, Illinois). Descriptive statistics were
calculated for all 30 soft-tissue variables at the three
time periods: pre-treatment (T1), post-treatment (T2), and
long-term (T3). Paired t-tests using a significance level
of p<0.05 were performed to assess differences according to
gender, Angle Classification, and treatment rendered
(extraction versus non-extraction).
Untreated Sample
The treated sample was compared to a standard of
growth and development established by Lemery29 in 2006. His
sample consisted of 98 untreated subjects who participated
in the Bolton Growth Studies at Case Western Reserve
University in Cleveland, Ohio. To be included in the study,
subjects possessed cephalometric records for at least the
first three established time points being studied. The four
age grades involved were: 6-10, 12-15, 18-22, and 50-60
years of age. These time periods were thought to represent
a typical pre-treatment, treatment, post-treatment, and a
mature age.
Graphs and tables were created using Microsoft Word
and Microsoft Excel, Microsoft Office Edition 2003,
41
(Microsoft Corporation, Redmond, Washington). Average
profile images were created using Adobe Photoshop CS2,
(Adobe Systems, Seattle, Washington) utilizing the mean x-y
coordinates each group at each age grade.
42
Results
Paired t-tests were used to analyze the 30 soft-tissue
measures taken on all 48 subjects across each time point
(T1-T2 and T2-T3). The subjects were further analyzed by
gender, Angle classification, and treatment differences.
Comparing males and females at T1 ( x =13.37 years)
(Table 3.1) males are significantly larger than females.
The soft tissue profile of males shows 3-5mm greater
anteroposterior prominence than females. These differences
were significant in the upper face, but not in the chin
region. In the vertical dimension, the lower 2/3 of the
face was significantly different in males and females. In
the lip region, the male lips and stomion were located more
inferiorly than in females by 3-5mm. The male chin was 78mm more inferior than the female chin.
At T2 ( x =16.25 years) (Table 3.2) most male and female
soft tissue measurements were significantly different. Of
the 30 measures, 26 demonstrated sexual dimorphism. Males
are larger in all aspects than females by 5-8mm in the
anteroposterior dimension. Vertically, the male nose is 23mm more inferior, while the lips are 3-6mm more inferior
than in females. The soft tissue chin is 6-8mm more
inferior than in females.
43
Table 3.1: Comparison of Males and Females
Males
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
V-Nasion'
2.8 ± 2.3
H-Nasion'
81.3 ± 4.1
V-Rhinion'
20.4 ± 3.3
H-Rhinion'
87.1 ± 5.3
V-Superior Nasal Tip
36.0 ± 3.7
H-Superior Nasal Tip
98.4 ± 6.7
V-Pronasale
43.7 ± 4.5
H-Pronasale
101.9 ± 6.8
V-Inferior Nasal Tip
50.6 ± 4.9
H-Inferior Nasal Tip
99.1 ± 6.6
V-Columella
53.1 ± 4.7
H-Columella
95.1 ± 6.5
V-Subnasale
56.6 ± 4.9
H-Subnasale
88.9 ± 6.3
V-Superior Labrale Sulcus
63.7 ± 5.8
H-Superior Labrale Sulcus
87.2 ± 5.9
V-Labrale Superius
73.4 ± 6.2
H-Labrale Superius
89.5 ± 5.9
V-Stomion
79.3 ± 5.4
H-Stomion
83.4 ± 6.1
V-Labrale Inferius
87.8 ± 5.9
H-Labrale Inferius
86.1 ± 6.8
V-Labiomental Fold
93.5 ± 6.6
H-Labiomental Fold
77.6 ± 7.4
V-Pogonion'
112.1 ± 7.6
H-Pogonion'
77.1 ± 8.8
V-Gnathion'
116.3 ± 8.1
H-Gnathion'
75.2 ± 9.1
V-Menton'
119.8 ± 8.4
H-Menton'
72.2 ± 9.1
T1 ( x age=13.4 years); * denotes p≤0.05; †
p≤0.001
44
at T1
Females
Sig
t
(2-tailed)
x ±SD(mm)
2.8 ± 1.6 .03
.977
77.9 ± 3.8 3.0
.004
19.9 ± 3.4
.4
.661
83.2 ± 4.3 2.8
†.007
34.5 ± 3.8 1.3
.204
94.5 ± 5.4 2.2
*.028
41.6 ± 3.5 1.8
.085
97.5 ± 5.9 2.4
*.019
47.9 ± 3.6 2.2
*.035
94.5 ± 6.1 2.5
*.015
50.7 ± 3.7 1.9
.057
90.1 ± 5.6 2.8
†.006
54.2 ± 3.3 2.0
*.046
84.1 ± 4.9 2.9
†.005
60.2 ± 3.9 2.5
*.018
82.3 ± 5.1 3.1
†.003
68.4 ± 4.6 3.2
†.003
84.4 ± 5.7 3.1
†.004
74.2 ± 4.2 3.6
†.001
78.5 ± 5.5 2.9
†.005
82.3 ± 4.9 3.5
‡.001
81.3 ± 5.8 2.6
*.014
88.4 ± 5.6 2.9
†.006
73.9 ± 6.1 1.9
.068
104.9 ± 6.7 3.4
‡.001
74.1 ± 8.9 1.1
.244
109.1 ± 6.8 3.3
†.002
72.3 ± 9.4 1.1
.279
112.7 ± 6.9 3.2
†.003
69.3 ± 10.0 1.1
.295
denotes p≤0.01; ‡ denotes
Table 3.2: Comparison of Males and Females at T2
Measure
V=Vertical; H=Horizontal
x
Males
±SD(mm)
V-Nasion'
1.9 ± 1.2
H-Nasion'
84.5 ± 3.6
V-Rhinion'
20.5 ± 3.5
H-Rhinion'
91.7 ± 4.4
V-Superior Nasal Tip
37.5 ± 3.9
H-Superior Nasal Tip
104.0 ± 5.4
V-Pronasale
46.5 ± 4.2
H-Pronasale
107.9 ± 5.7
V-Inferior Nasal Tip
54.3 ± 4.0
H-Inferior Nasal Tip
104.2 ± 5.6
V-Columella
56.7 ± 4.0
H-Columella
98.9 ± 5.4
V-Subnasale
59.9 ± 3.9
H-Subnasale
91.9 ± 6.0
V-Superior Labrale Sulcus
66.0 ± 4.4
H-Superior Labrale Sulcus
88.9 ± 5.8
V-Labrale Superius
76.7 ± 4.5
H-Labrale Superius
90.6 ± 5.7
V-Stomion
82.4 ± 4.8
H-Stomion
84.1 ± 6.1
V-Labrale Inferius
91.1 ± 5.7
H-Labrale Inferius
87.4 ± 6.5
V-Labiomental Fold
99.3 ± 6.4
H-Labiomental Fold
79.7 ± 6.5
V-Pogonion'
117.8 ± 7.1
H-Pogonion'
81.1 ± 7.9
V-Gnathion'
122.4 ± 6.8
H-Gnathion'
79.7 ± 8.1
V-Menton'
126.4 ± 6.9
H-Menton'
77.1 ± 8.0
T2 ( x age=16.3 years);
* denotes p≤0.05; †
p≤0.001
45
Sig
(2tailed)
2.1
.723
.473
3.1 5.148
‡.000
4.0
.469
.641
3.4 5.473
‡.000
4.0
.633
.530
4.3 5.247
‡.000
4.2 1.640
.108
4.4 5.506
‡.000
3.9 2.358
*.023
4.6 5.194
‡.000
3.8 2.117
*.040
4.9 5.066
‡.000
3.6 2.037
*.048
4.2 4.961
‡.000
3.8 2.539
†.015
4.5 4.710
‡.000
3.8 3.898
‡.000
5.1 4.339
‡.000
4.2 3.819
‡.000
5.3 4.213
‡.000
5.2 3.614
‡.001
5.5 3.979
‡.000
6.4 3.258
†.002
6.3 3.150
†.003
8.1 2.993
†.004
8.7 2.556
*.014
8.0 3.289
†.002
9.2 2.631
*.012
7.9 3.487
‡.001
10.0 2.698
†.010
p≤0.01; ‡ denotes
Females
x ±SD(mm)
2.3 ±
79.5 ±
21.0 ±
85.4 ±
36.8 ±
96.6 ±
44.5 ±
99.7 ±
51.6 ±
96.4 ±
54.3 ±
91.3 ±
57.7 ±
84.4 ±
64.0 ±
81.8 ±
72.0 ±
83.7 ±
77.4 ±
77.1 ±
85.3 ±
80.5 ±
93.2 ±
73.9 ±
111.1 ±
75.0 ±
115.3 ±
73.1 ±
118.9 ±
70.0 ±
denotes
t
At T3 ( x =35.02 years) (Table 3.3) males and females
diverge even further. Males continue to be significantly
larger in the anteroposterior and vertical dimensions at
nearly all time points by an increasing amount (6-10mm).
Male soft tissue chin measurements are located more
anteriorly than females by 10mm and more inferiorly by 89mm. The male nose and lips are located 9-10mm more
anterior than in females. Vertically, the male nose is
located 3-4mm more inferior than in females, while the lips
are located 4-6mm more inferiorly than in females.
In
general, the male profile is located more anterior and
inferior compared to the female counterpart.
46
Table 3.3: Comparison of Males and Females at T3
Measure
Males
Females
Sig
t
V=Vertical;
(2-tailed)
x
x
±SD(mm)
±SD(mm)
H=Horizontal
V-Nasion'
3.6 ± 1.9
3.4 ±
2.2
.332
.742
H-Nasion'
87.7 ± 3.4
81.3 ±
3.7 6.288
‡.000
V-Rhinion'
20.6 ± 3.9
21.0 ±
4.9
.331
.742
H-Rhinion'
94.5 ± 3.6
87.8 ±
3.2 6.860
‡.000
V-Superior Nasal Tip
41.2 ± 4.3
39.2 ±
4.7 1.492
.142
H-Superior Nasal Tip
108.8 ± 4.6
99.8 ±
4.1 7.167
‡.000
V-Pronasale
51.1 ± 4.8
47.9 ±
4.6 2.342
*.024
H-Pronasale
112.3 ± 4.9 102.8 ±
4.4 7.150
‡.000
V-Inferior Nasal Tip
58.3 ± 4.8
54.5 ±
4.4 2.871
†.006
H-Inferior Nasal Tip
108.5 ± 5.2
98.6 ±
4.5 7.073
‡.000
V-Columella
60.7 ± 4.3
56.8 ±
4.2 3.235
†.002
H-Columella
102.7 ± 5.3
93.0 ±
4.9 6.566
‡.000
V-Subnasale
63.1 ± 4.5
59.7 ±
3.7 2.863
†.006
H-Subnasale
94.0 ± 6.0
85.1 ±
4.2 6.004
‡.000
V-Superior Labrale Sulcus
71.0 ± 4.3
66.5 ±
3.8 3.863
‡.000
H-Superior Labrale Sulcus
91.0 ± 5.4
82.4 ±
4.7 5.841
‡.000
V-Labrale Superius
82.1 ± 4.7
76.0 ±
4.4 4.614
‡.000
H-Labrale Superius
92.1 ± 5.6
83.7 ±
5.5 5.286
‡.000
V-Stomion
86.3 ± 4.0
80.8 ±
4.4 4.456
‡.000
H-Stomion
86.7 ± 5.5
77.8 ±
5.6 5.576
‡.000
V-Labrale Inferius
93.6 ± 4.7
89.2 ±
5.1 3.107
‡.000
H-Labrale Inferius
90.3 ± 5.9
81.4 ±
5.8 5.267
‡.000
V-Labiomental Fold
104.2 ± 4.8
97.6 ±
5.9 4.303
†.003
H-Labiomental Fold
83.9 ± 6.3
75.4 ±
6.9 4.448
‡.000
V-Pogonion'
124.9 ± 6.7 116.5 ±
8.0 3.981
‡.000
H-Pogonion'
87.2 ± 8.2
77.0 ±
9.5 3.986
‡.000
V-Gnathion'
129.7 ± 6.5 120.7 ±
7.6 4.391
‡.000
H-Gnathion'
85.6 ± 8.8
75.2 ± 10.1 3.821
‡.000
V-Menton'
129.3 ± 6.6 120.3 ±
7.5 4.832
‡.000
H-Menton'
82.7 ± 9.1
72.2 ± 10.6 3.705
‡.001
T3 ( x age=35.0 years); * denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
47
When comparing the subjects based on their Angle
Classification, no significant differences were found
between Class I and Class II subjects. At T1 (Table 3.4)
and T2 (Table 3.5), Class II subjects were 1-2mm larger in
the anteroposterior dimension, but 1-2mm smaller in the
vertical dimension.
Surprisingly, Class II individuals had
1-2mm more anterior placement of the chin at T1 and T2, but
this difference had disappeared by T3 (Table 3.6). Even
though insignificant, the nose of Class II subjects moved
vertically to a greater extent than Class I subjects.
Stomion moved distally in Class II subjects while the chin
moved more anteriorly in Class II subjects.
48
Table 3.4: Comparison of Class I and Class II at T1
Sig
Measure
Class I
Class II
t
(2V=Vertical;
x ±SD(mm)
x ±SD(mm)
tailed)
H=Horizontal
V-Nasion'
2.2 ±
1.3
3.4 ± 2.3 -2.181
.034
H-Nasion'
78.8 ±
4.2
80.5 ± 4.2
1.359
.181
V-Rhinion'
19.8 ±
3.1
20.5 ± 3.5
-.721
.474
H-Rhinion'
84.2 ±
5.2
86.2 ± 5.0
1.350
.184
V-Superior Nasal Tip
35.6 ±
3.7
34.9 ± 3.9
.632
.530
H-Superior Nasal Tip
95.8 ±
6.2
97.1 ± 6.5
.665
.509
V-Pronasale
43.2 ±
4.0
42.1 ± 4.2
.922
.361
H-Pronasale
99.1 ±
6.6 100.4 ± 6.9
.655
.516
V-Inferior Nasal Tip
49.9 ±
4.3
48.7 ± 4.7
.960
.342
H-Inferior Nasal Tip
96.0 ±
6.7
97.6 ± 6.8
.851
.399
V-Columella
52.5 ±
4.1
51.4 ± 4.5
.909
.368
H-Columella
91.9 ±
6.6
93.3 ± 6.5
.780
.439
V-Subnasale
56.1 ±
4.1
54.7 ± 4.5
1.181
.244
H-Subnasale
85.8 ±
6.1
87.4 ± 6.0
.913
.366
V-Superior Labrale Sulcus
62.7 ±
5.0
61.2 ± 5.4
.999
.323
H-Superior Labrale Sulcus
84.0 ±
6.1
85.5 ± 6.0
.828
.412
V-Labrale Superius
71.3 ±
5.5
70.5 ± 6.5
.414
.681
H-Labrale Superius
86.3 ±
6.0
87.6 ± 6.6
.760
.451
V-Stomion
77.0 ±
5.0
76.5 ± 5.8
.307
.760
H-Stomion
80.0 ±
6.0
81.9 ± 6.4
1.098
.278
V-Labrale Inferius
85.9 ±
5.8
84.3 ± 6.2
.908
.369
H-Labrale Inferius
83.3 ±
6.6
84.1 ± 6.9
.420
.677
V-Labiomental Fold
91.7 ±
6.4
90.2 ± 6.9
.805
.425
H-Labiomental Fold
75.7 ±
6.8
76.0 ± 7.2
.148
.883
V-Pogonion'
109.5 ±
7.9 107.6 ± 8.1
.829
.412
H-Pogonion'
75.5 ±
9.1
75.8 ± 8.8
.106
.916
V-Gnathion'
113.8 ±
8.3 111.6 ± 8.1
.899
.373
H-Gnathion'
73.3 ±
9.6
74.2 ± 9.1
.308
.759
V-Menton'
117.3 ±
8.7 115.1 ± 8.2
.910
.368
H-Menton'
70.0 ± 10.0
71.5 ± 9.3
.550
.585
T1 ( x age=13.4 years);
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
49
Table 3.5: Comparison of Class I and Class II at T2
Sig
Measure
Class I
Class II
t
(2V=Vertical;
x ±SD(mm)
x ±SD(mm)
tailed)
H=Horizontal
V-Nasion'
2.3 ± 1.6
2.0 ±
1.8
.542
.590
H-Nasion'
81.1 ± 3.9
82.7 ±
4.3 1.352
.183
V-Rhinion'
21.2 ± 3.8
20.3 ±
3.8
.846
.402
H-Rhinion'
87.7 ± 4.8
89.3 ±
5.2 1.049
.300
V-Superior Nasal Tip
37.9 ± 3.9
36.4 ±
3.8 1.298
.201
H-Superior Nasal Tip
99.5 ± 5.8 100.9 ±
6.3
.741
.462
V-Pronasale
46.6 ± 4.4
44.5 ±
3.9 1.782
.082
H-Pronasale
103.1 ± 6.1 104.3 ±
6.9
.652
.517
V-Inferior Nasal Tip
53.9 ± 4.5
52.1 ±
3.7 1.476
.147
H-Inferior Nasal Tip
99.5 ± 6.0 100.9 ±
6.7
.790
.434
V-Columella
56.3 ± 4.5
54.6 ±
3.5 1.494
.142
H-Columella
94.1 ± 6.3
95.8 ±
6.4
.915
.365
V-Subnasale
59.4 ± 4.3
58.1 ±
3.4 1.107
.274
H-Subnasale
87.3 ± 5.9
88.8 ±
6.8
.816
.419
V-Superior Labrale Sulcus
66.0 ± 4.8
64.8 ±
3.8
.970
.337
H-Superior Labrale Sulcus
84.5 ± 5.8
85.9 ±
6.7
.763
.450
V-Labrale Superius
74.8 ± 5.2
73.9 ±
4.3
.663
.511
H-Labrale Superius
86.6 ± 6.0
87.5 ±
6.9
.460
.648
V-Stomion
80.7 ± 5.5
79.0 ±
4.6 1.116
.270
H-Stomion
80.0 ± 6.2
81.0 ±
7.1
.548
.587
V-Labrale Inferius
89.4 ± 6.3
86.9 ±
5.9 1.426
.161
H-Labrale Inferius
83.6 ± 6.6
84.1 ±
7.3
.264
.793
V-Labiomental Fold
96.9 ± 6.9
95.4 ±
7.1
.750
.457
H-Labiomental Fold
76.2 ± 6.6
77.3 ±
7.3
.520
.606
V-Pogonion'
114.9 ± 8.8 113.8 ±
7.9
.481
.633
H-Pogonion'
77.6 ± 8.0
78.3 ±
9.6
.299
.766
V-Gnathion'
119.3 ± 8.7 118.2 ±
7.8
.470
.640
H-Gnathion'
75.8 ± 8.4
76.8 ± 10.0
.389
.699
V-Menton'
123.2 ± 8.7 121.9 ±
8.0
.507
.614
H-Menton'
72.7 ± 9.0
74.2 ± 10.4
.514
.609
T2 ( x age=16.3 years); * denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
50
Table 3.6: Comparison of Class I and Class II at T3
Measure
Class I
Class II
Sig
t
V=Vertical;
(2-tailed)
x
x
±SD(mm)
±SD(mm)
H=Horizontal
V-Nasion'
3.1 ± 1.6
3.8 ± 2.5 1.192
.240
H-Nasion'
83.5 ± 4.5
85.6 ± 4.9 1.552
.127
V-Rhinion'
20.7 ± 4.0
20.9 ± 4.8
.186
.853
H-Rhinion'
90.0 ± 4.3
92.3 ± 5.1 1.668
.102
V-Superior Nasal Tip
40.3 ± 4.1
40.1 ± 5.2
.130
.897
H-Superior Nasal Tip
103.2 ± 5.7 105.4 ± 6.7 1.211
.232
V-Pronasale
49.8 ± 4.6
49.2 ± 5.3
.431
.669
H-Pronasale
106.6 ± 6.1 108.5 ± 7.4
.937
.353
V-Inferior Nasal Tip
56.7 ± 4.6
56.1 ± 5.3
.435
.666
H-Inferior Nasal Tip
102.5 ± 6.2 104.6 ± 7.6 1.012
.317
V-Columella
59.1 ± 4.5
58.4 ± 4.9
.458
.649
H-Columella
96.9 ± 6.5
98.8 ± 7.6
.906
.370
V-Subnasale
61.7 ± 4.1
61.2 ± 4.8
.378
.707
H-Subnasale
88.6 ± 6.5
90.5 ± 7.1
.972
.336
V-Superior Labrale Sulcus
68.8 ± 4.4
68.7 ± 4.9
.099
.921
H-Superior Labrale Sulcus
86.1 ± 6.3
87.3 ± 7.1
.615
.542
V-Labrale Superius
79.0 ± 5.5
79.1 ± 5.6
.097
.923
H-Labrale Superius
87.3 ± 6.1
88.5 ± 7.9
.551
.585
V-Stomion
83.6 ± 5.2
83.5 ± 5.0
.037
.971
H-Stomion
81.9 ± 6.7
82.6 ± 7.6
.359
.721
V-Labrale Inferius
91.5 ± 5.4
91.2 ± 5.4
.193
.848
H-Labrale Inferius
86.0 ± 7.1
85.8 ± 7.7
.060
.952
V-Labiomental Fold
100.8 ± 6.7 101.0 ± 6.0
.132
.896
H-Labiomental Fold
79.5 ± 7.4
79.7 ± 8.3
.108
.915
V-Pogonion'
120.6 ± 8.5 120.8 ± 8.6
.066
.948
H-Pogonion'
82.0 ± 8.9
82.3 ± 11.5
.103
.919
V-Gnathion'
125.2 ± 8.5 125.2 ± 8.3
.002
.999
H-Gnathion'
80.2 ± 9.4
80.6 ± 12.1
.122
.903
V-Menton'
129.1 ± 8.7 128.8 ± 8.5
.119
.906
H-Menton'
77.2 ± 9.7
77.8 ± 12.7
.187
.852
T3 ( x age=35.0 years); * denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
51
When evaluating the sample by grouping them into
extraction and non-extraction treatment categories, many
differences were found at each time point. At T1 (Table
3.7), individuals treated non-extraction were significantly
larger in the anteroposterior dimension. Non-extraction
subjects’ noses and lips were 5-6mm more anterior and the
soft-tissue chin was 8-10mm more anterior than those
subjects treated with extractions. Vertically, nonextraction subjects were larger than extraction subjects at
nearly all measurements, but not significantly.
At T2 (Table 3.8), individuals treated non-extraction
continued to be larger in the anteroposterior dimension.
The nose of non-extraction subjects was 4-5mm more anterior
and the lips were 5-7mm more anterior than subjects treated
with extractions. Also, the soft-tissue chin was 8-9mm
larger in those treated non-extraction. Vertically, the
treatment differences were not significant, but nonextraction subjects were slightly larger at nearly all
measurements.
52
Table 3.7: Comparison of Extraction and Non-extraction at T1
Sig
Measure
Extraction
Non-extraction
t
(2V=Vertical;
x ±SD(mm)
x ±SD(mm)
tailed)
H=Horizontal
V-Nasion'
2.1 ± 2.1
3.4 ± 1.6 2.387
†.021
H-Nasion'
78.1 ± 4.4
81.2 ± 3.6 2.670
†.010
V-Rhinion'
20.5 ± 3.3
19.8 ± 3.3
.783
.438
H-Rhinion'
83.1 ± 5.3
87.3 ± 4.2 3.033
†.004
V-Superior Nasal Tip
34.9 ± 3.8
35.5 ± 3.8
.540
.592
H-Superior Nasal Tip
93.5 ± 6.2
99.4 ± 5.1 3.582
‡.001
V-Pronasale
42.0 ± 4.1
43.3 ± 4.0 1.117
.270
H-Pronasale
96.7 ± 6.3
102.8 ± 5.8 3.472
‡.001
V-Inferior Nasal Tip
48.7 ± 4.6
49.9 ± 4.4
.889
.379
H-Inferior Nasal Tip
93.8 ± 6.3
99.8 ± 5.8 3.459
‡.001
V-Columella
51.4 ± 4.5
52.5 ± 4.2
.855
.379
H-Columella
89.6 ± 6.2
95.6 ± 5.5 3.540
‡.001
V-Subnasale
54.4 ± 4.4
56.4 ± 4.0 1.604
.115
H-Subnasale
84.0 ± 6.0
89.1 ± 5.0 3.150
†.003
V-Superior Labrale Sulcus
61.3 ± 5.7
62.6 ± 4.7
.863
.392
H-Superior Labrale Sulcus
82.2 ± 5.9
87.3 ± 5.0 3.252
†.002
V-Labrale Superius
70.0 ± 6.6
71.9 ± 5.2 1.140
.260
H-Labrale Superius
84.4 ± 6.1
89.5 ± 5.4 3.090
†.003
V-Stomion
76.2 ± 6.0
77.3 ± 4.8
.669
.507
H-Stomion
78.4 ± 6.3
83.5 ± 5.1 2.987
†.005
V-Labrale Inferius
84.6 ± 6.3
85.5 ± 5.9
.542
.591
H-Labrale Inferius
80.7 ± 6.9
86.7 ± 5.1 3.393
‡.001
V-Labiomental Fold
89.8 ± 7.6
92.1 ± 5.3 1.235
.223
H-Labiomental Fold
73.0 ± 7.4
78.6 ± 5.3 2.988
†.004
V-Pogonion'
107.6 ± 9.9
109.5 ± 5.6
.810
.422
H-Pogonion'
71.3 ± 8.7
80.0 ± 6.8 3.827
‡.000
V-Gnathion'
111.9 ± 10.2
113.5 ± 5.7
.708
.483
H-Gnathion'
69.2 ± 8.9
78.4 ± 7.1 3.956
‡.000
V-Menton'
115.2 ± 10.6
117.2 ± 5.6
.844
.403
H-Menton'
65.8 ± 9.1
75.7 ± 7.5 4.106
‡.000
T1 ( x age=13.4 years);
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
53
Table 3.8: Comparison of Extraction and Non-extraction at T2
Sig
Measure
Extraction
Non-extraction
t
(2V=Vertical;
x ±SD(mm)
x ±SD(mm)
tailed)
H=Horizontal
V-Nasion'
1.7 ± 1.9
2.6 ± 1.4 1.849
.071
H-Nasion'
80.9 ± 4.4
83.0 ± 3.6 1.724
.092
V-Rhinion'
21.9 ± 3.8
19.6 ± 3.4 2.137
*.038
H-Rhinion'
86.8 ± 5.2
90.2 ± 4.3 2.434
*.019
V-Superior Nasal Tip
37.7 ± 4.1
36.5 ± 3.7 1.102
.276
H-Superior Nasal Tip
97.7 ± 5.9
102.8 ± 5.3 3.121
†.003
V-Pronasale
46.1 ± 4.6
45.0 ± 3.9 0.949
.348
H-Pronasale
101.3 ± 6.3
106.2 ± 5.7 2.775
†.008
V-Inferior Nasal Tip
53.7 ± 4.4
52.2 ± 3.9 1.281
.207
H-Inferior Nasal Tip
97.9 ± 5.9
102.7 ± 6.0 2.815
†.007
V-Columella
56.3 ± 4.4
54.5 ± 3.6 1.498
.141
H-Columella
92.3 ± 5.4
97.8 ± 6.1 3.302
†.002
V-Subnasale
59.3 ± 4.2
58.2 ± 3.5 0.973
.336
H-Subnasale
85.7 ± 6.4
90.6 ± 5.4 2.880
†.006
V-Superior Labrale Sulcus
66.0 ± 4.9
64.9 ± 3.7 0.878
.385
H-Superior Labrale Sulcus
82.5 ± 6.2
88.0 ± 5.2 3.300
†.002
V-Labrale Superius
74.6 ± 5.7
74.0 ± 3.7 0.478
.635
H-Labrale Superius
84.4 ± 6.4
89.9 ± 5.3 3.200
†.003
V-Stomion
80.0 ± 6.0
79.5 ± 4.2 0.299
.768
H-Stomion
77.4 ± 6.6
83.8 ± 5.2 3.693
‡.001
V-Labrale Inferius
88.7 ± 6.9
87.5 ± 5.4 0.662
.512
H-Labrale Inferius
80.7 ± 6.8
87.2 ± 5.4 3.630
‡.001
V-Labiomental Fold
95.7 ± 8.7
96.6 ± 5.2 0.399
.692
H-Labiomental Fold
73.7 ± 6.7
80.0 ± 5.8 3.413
‡.001
V-Pogonion'
114.6 ± 10.3
114.2 ± 6.0 0.161
.873
H-Pogonion'
73.9 ± 8.5
82.2 ± 7.1 3.677
‡.001
V-Gnathion'
119.1 ± 10.3
118.4 ± 5.7 0.316
.754
H-Gnathion'
72.1 ± 8.7
80.8 ± 7.7 3.639
‡.001
V-Menton'
123.1 ± 10.5
122.0 ± 5.7 0.420
.676
H-Menton'
69.1 ± 8.6
78.1 ± 8.7 3.589
‡.001
T2 ( x age=16.3 years);
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
54
At T3 (Table 3.9), while non-significant, subjects
treated with extractions had noses that were 2-3mm more
inferior and lips 1mm more inferior than those subjects
treated non-extraction. Extraction subjects’ soft-tissue
chin was 3-4mm longer than those treated non-extraction. In
the anteroposterior dimension, nearly all measurements were
significantly different between non-extraction and
extraction subjects. Those treated non-extraction had noses
that were 5-7mm more anterior and lips 6-7mm more anterior
than those treated with extractions. Also, the soft-tissue
chin of subjects treated non-extraction was more anteriorly
located by 9-12mm.
55
Table 3.9: Comparison of Extraction and Non-extraction at T3
Sig
Measure
Extraction
Non-extraction
t
(2V=Vertical;
x ±SD(mm)
x ±SD(mm)
tailed)
H=Horizontal
V-Nasion'
3.5 ± 2.3
3.5 ± 1.8
.014
.989
H-Nasion'
83.5 ± 4.5
85.6 ± 4.9 1.552
.127
V-Rhinion'
22.2 ± 4.5
19.4 ± 3.8 2.373
*.022
H-Rhinion'
89.7 ± 4.3
92.6 ± 4.9 2.228
*.031
V-Superior Nasal Tip
41.1 ± 5.5
39.3 ± 3.3 1.399
.168
H-Superior Nasal Tip
101.6 ± 5.5
107.0 ± 5.9 3.292
†.002
V-Pronasale
50.3 ± 6.1
48.6 ± 3.3 1.216
.230
H-Pronasale
104.7 ± 5.8
110.4 ± 6.4 3.192
†.003
V-Inferior Nasal Tip
57.3 ± 6.1
55.5 ± 3.3 1.284
.206
H-Inferior Nasal Tip
100.4 ± 6.0
106.7 ± 6.5 3.477
‡.001
V-Columella
59.6 ± 5.8
58.0 ± 3.0 1.191
.240
H-Columella
94.4 ± 5.7
101.3 ± 6.7 3.834
‡.000
V-Subnasale
61.4 ± 5.6
61.4 ± 2.9 0.016
.987
H-Subnasale
86.7 ± 6.4
92.4 ± 6.1 3.094
†.003
V-Superior Labrale Sulcus
69.1 ± 5.7
68.4 ± 3.3 0.528
.600
H-Superior Labrale Sulcus
83.6 ± 5.6
89.7 ± 6.0 3.500
‡.001
V-Labrale Superius
79.6 ± 6.7
78.5 ± 3.9
.701
.487
H-Labrale Superius
84.6 ± 5.9
91.2 ± 6.4 3.712
‡.001
V-Stomion
84.0 ± 6.3
83.1 ± 3.3
.576
.568
H-Stomion
79.0 ± 6.0
85.5 ± 6.6 3.593
‡.001
V-Labrale Inferius
91.9 ± 6.6
90.8 ± 3.8
.710
.481
H-Labrale Inferius
82.4 ± 6.2
89.3 ± 6.9 3.675
‡.001
V-Labiomental Fold
101.2 ± 7.5
100.6 ± 5.0
.327
.745
H-Labiomental Fold
76.0 ± 6.6
83.2 ± 7.4 3.544
‡.001
V-Pogonion'
122.5 ± 10.3
118.7 ± 5.7 1.510
.138
H-Pogonion'
77.4 ± 8.7
86.8 ± 9.4 3.602
‡.001
V-Gnathion'
127.1 ± 10.2
123.2 ± 5.6 1.638
.108
H-Gnathion'
75.1 ± 9.2
85.7 ± 9.7 3.910
‡.000
V-Menton'
130.7 ± 10.4
127.1 ± 5.8 1.470
.148
H-Menton'
71.6 ± 9.3
83.3 ± 9.8 4.231
‡.000
T3 ( x age=35.0 years);
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes
p≤0.001
56
Discussion
This study evaluated the soft tissue profile at three
time points: pre-treatment ( x age 13.37), post-treatment
( x age 16.25), and at a mature age ( x age 35.02). Standard
cephalometric techniques were used to evaluate and assess
the soft tissue profile and how, over time, it changes with
growth and treatment. The differences between Class I and
Class II skeletal patterns, extraction and non-extraction
treatments and between males and females were compared and
contrasted with the changes seen in untreated individuals.
The results showed that treated males were
significantly larger than treated females in the
anteroposterior and vertical dimensions. The male softtissue profile is located more anterior and inferior
compared to the female counterpart. No significant
differences were found between Class I and Class II
subjects. Subjects treated non-extraction were
significantly larger in the anteroposterior dimension.
Their soft tissue profiles were located more anterior (512mm) than those treated with extractions.
The results were compared to those found by Lemery in
2006.29 He conducted a longitudinal study comparing soft
tissue growth according to gender and Angle classification.
Using a sample of 98 subjects from the Bolton Growth Study,
57
four age grades were evaluated: 6-10, 12-15, 18-22, and 5060 years. He found the amount and direction of soft tissue
growth varies with gender, Angle classification, and time.
This study relied on Lemery’s research design and used his
results as a control for the comparison of orthodontically
treated versus untreated individuals.
Gender
When comparing treated (Figure 3.3) and untreated
(Figure 3.5) females, the nose and chin in both groups grew
downward and forward. The lips, however, in the treated
sample had a more vertical component of growth, while in
the untreated sample, the lips grew downward and forward.
When evaluating males, the nose and chin in both
treated (Figure 3.3) and untreated (Figure 3.5) subjects
had a very similar downward and forward pattern of growth.
The upper lip in the treated subjects, however, had a more
horizontal vector of growth. In the untreated subjects at
the oldest ages the upper lip moved distally and vertically
while stomiom had a slight vertical component.
Angle Classification
When assessing the differences between treated
(Figure 3.3) and untreated (Figure 3.5) Class I subjects,
many differences were found. In the treated subjects, the
nose and chin had a more horizontal component of growth,
58
59
Female
Male
Class I
Class II
Figure 3.3: Composite profiles of treated subjects illustrating landmark changes by gender and
Class. Average ages: T1=13.37 years T2=16.25 years T3=35.02 years
59
60
Non-extraction
Extraction
Figure 3.4: Composite profiles of treated subjects illustrating landmark changes by treatment rendered.
Average ages: T1=13.37 years T2=16.25 years T3=35.02 years
60
61
Female
Male
Class I
Class II
Figure 3.5: Composite profiles of untreated subjects illustrating landmark changes by gender and class.
Average ages: T1=6-10 years T2=12-15 years T3=18-22 years T4=50-60 years
Modified from Lemery29
61
while the untreated subjects had a vertical component. The
lips also showed that treatment had an effect. At the
oldest ages, the lips in the untreated Class I subjects
moved forward, then vertically, while in the treated
subjects they had a more horizontal vector of growth.
Class II subjects also showed distinct differences.
The noses of treated (Figure 3.3) and untreated (Figure
3.5) subjects were very similar with a downward and forward
growth pattern, but the chins showed considerable
variation. In untreated Class II subjects, the chin had a
horizontal component of growth. Lemery in 2006 described
this as a reversal of a once mandibular deficient profile.29
Class II subjects at the oldest ages surpassed the Class I
subjects making up for their recessive chins. However, in
the treated Class II subjects, the chin had a more vertical
component of growth. This could be due to the extrusive
nature of Class II mechanics. The lips also showed
divergence between treated and untreated subjects. Similar
to the chin, untreated subjects had lips that grew more
horizontally, while treated subjects showed a more vertical
direction of growth.
The differences described previously between treated
and untreated Class I and Class II subjects may be due to
differences in the sample ages or due to treatment.
62
Statistically, no differences were found between treated
Class I and Class II subjects. This may have occurred
because both males and females are contained in the Class I
and Class II groups possibly masking important differences.
Further subdividing the samples also revealed that
orthodontic treatment affects the face long-term. When
comparing Class I females, both treated (Figure 3.6) and
untreated (Figure 3.7) subjects’ nose grew downward and
forward, but the treated sample had a more horizontal
component of growth. The lips maintained about the same
direction of growth, but the chin did not. The treated
Class I female chin grew in a substantially more horizontal
pattern than those that were not treated. The untreated
sample had a straight vertical, and even distal, vector of
growth in the chin area. Therefore, for Class I females,
orthodontic treatment appears to positively affect the
soft-tissue profile, especially in the area of the lips and
chin.
The Class II females did not have as much variation
between the treated (Figure 3.6) and untreated (Figure 3.7)
samples in the nose or chin areas. The treated Class II
females had slightly more horizontal nose growth, but had
about the same downward and forward growth of the chin. The
untreated Class II females had a substantial anterior gain
63
64
Class I Female
Class II Female
Class I Male
Class II Male
Figure 3.6: Composite profiles illustrating landmark changes in treated subjects: female, male, Class I,
and Class II. Average ages: T1=13.37 years T2=16.25 years T3=35.02 years
64
65
Class I Female
Class II Female
Class I Male
Class II Male
Figure 3.7: Composite profiles illustrating landmark changes in untreated subjects: female, male, Class
I, and Class II Modified from Lemery29, 2006. Average ages: T1=6-10 years T2=12-15 years T3=18-22 years
T4=50-60 years
66
that aided in the recovery from a once mandibular deficient
profile. The lips, however, did show differences. The
treated subjects had a backward, then downward and forward
direction of growth, especially in the lower lip. The
untreated subjects had a downward and forward direction,
then at the oldest ages grew nearly straight vertical.
The Class I males displayed considerable differences
throughout the entire soft-tissue profile. The treated
Class I males (Figure 3.6) exhibited a more horizontal
component of growth in the nose, lips, and chin, while the
untreated males (Figure 3.7) grew vertically. In fact,
subnasale, the upper lip, and stomion in the untreated
subjects moved vertically and distally. Some of these
differences may be due to age differences of the sample.
Conversely, the Class II males expressed very little
differences in growth patterns between treated (Figure 3.6)
and untreated (Figure 3.7) subjects. The treated Class II
males showed slightly more vertical growth of the chin, but
the nose followed the same downward and forward trajectory
as the untreated sample. The upper lip, however, did show
some differences. The untreated Class II male had a
downward and forward growth vector, but at the oldest ages,
turned backward and vertical. The treated males continued
the downward and forward growth vector to the oldest ages.
67
When discussing the treated subjects it is important
to note that Class I females and Class II females show no
differences statistically. This is also true for Class I
males and Class II males. However, when looking at the
illustrations, some differences are evident. This lack of
statistical significance may be due to interactions within
the groupings as they contain both extraction and nonextraction treatments as well as Class I and Class II
subjects.
To evaluate how certain treatments and skeletal
patterns are affected by orthodontics, the treated sample
was further divided. In this situation, statistical
analysis was not possible due to the resultant small sample
sizes. Therefore, the following discussion is based on
calculated means that were used to create an illustration
of the soft tissue profile. It has been shown that there
were no statistically significant differences between Class
I and Class II females whether or not they were treated
with extractions or non-extraction. Also, the differences
between females treated with extractions or non-extraction
were only significant in the horizontal dimension. Thus,
interactions may be present, but this cannot be quantified
with the sample size (N=6 in each group; seen in figures
3.8 and 3.9).
68
When comparing females who were treated with or
without extractions and had a Class I or Class II
malocclusion, many differences were found (Figure 3.8). In
the chin region, non-extraction Class I females had a
downward and forward vector of growth, while non-extraction
Class II females were more horizontal and in greater
amount. Females that had extractions also grew differently
depending on Angle Classification. In the area of the chin,
Class I extraction subjects had a vertical component with
slight forward growth, while Class II extraction subjects
had a straight vertical component with slight backward
growth.
The lips of females also showed variations depending
on treatment and malocclusion. The non-extraction Class I
females had a downward and forward component of growth to
their lips. The extraction Class I females had distal
movement of their lips during treatment, but had some
recovery of that distal movement as they aged, especially
for the lower lip. The lips tended to grow downward and
forward, ending up nearly straight vertical from where they
began. Class I females treated with extractions had lips
that changed similarly to Class II females who were treated
non-extraction. These females had a distal component of
growth, and had a visually recognizable, but not
69
statistically significant, vertical vector of growth as
they aged. Class II females that were treated with
extractions had a backward and vertical growth of their
lips.
The noses of females treated with extractions were
very similar visually, although not significantly. Both
Class I and Class II females had a vertical component of
nose growth with a more downward than forward vector.
Conversely, non-extraction Class I and Class II females had
a horizontal component of nose growth with a more forward
than downward vector.
70
70
Non-extraction Class I
Non-extraction Class II
Extraction Class I
Extraction Class II
female
female
female
female
Table 3.8: Composite profiles of females illustrating landmark changes based on Angle Classification,
gender, and treatment rendered. Average ages: T1=13.37 years T2=16.25 years T3=35.02 years
71
Calculated means were also used to create an
illustration of the soft tissue profile of males. When
dividing the male subjects based on Angle Classification
and treatment rendered, unique characteristics were found
for each group (Figure 3.9). When evaluating the chin
region, both non-extraction Class I and Class II males and
extraction Class I males had a horizontal growth vector.
However, Class II males who were treated with extractions
had a visually recognizable, but not statistically
significant, vertical direction of growth.
The noses of males show many similarities. Class II
extraction and non-extraction, and Class I non-extraction
subjects all had a forward and downward growth of the nose.
Class I extraction males, however, had a more horizontal
component of growth.
Concerning the lips of males, many of the soft tissue
points of the lips showed subtle differences. Superior
labial sulcus relocated downward and forward in nonextraction and extraction Class II males and in extraction
Class II males, while it moved more horizontally in
extraction Class I males. Labrale superius had a downward
and forward vector of growth in non-extraction and
extraction Class II males. However, non-extraction Class I
males showed a horizontal, then straight vertical pattern
72
of growth in labrale superius, while Class I males treated
with extractions showed a straight vertical, then downward
and forward pattern of growth. Stomion also showed two
distinct patterns of growth. In the non-extraction Class I
and Class II males, stomion grew in a downward and forward
direction. In both Class I and Class II extraction males,
stomion had a backward and vertical movement throughout
treatment, then changed its course to a more forward
movement.
The labial mental fold throughout treatment in all
Class I males and non-extraction Class II males, had a
distinctly vertical vector of growth. The Class II
extraction group had a horizontal movement throughout
treatment. After treatment, the direction of the labial
mental fold changed in all groups. In both the extraction
and non-extraction Class II males, the labial mental fold
grew in a downward and forward direction. The nonextraction Class I male had a forward and downward
component of growth, while the extraction Class I male had
a straight horizontal vector of growth of the labial mental
fold at the oldest ages.
73
73
Non-extraction Class I
Non-extraction Class II
Extraction Class I
Male
Male
Male
Extraction Class II
Male
Figure 3.9: Composite profiles of males illustrating landmark changes based on Angle Classification,
gender, and treatment rendered. Average ages: T1=13.37 years T2=16.25 years T3=35.02 years
74
The illustrations show that extractions produce a very
different effect in males and females. Males grew more
horizontally and in greater amount, while females had a
more vertical vector of growth. Non-extraction males and
females both grew in a downward and forward direction, but
males had a greater amount of growth.
There are multiple limitations to this study. First,
this study utilized a small sample size (48 treated
subjects). It is difficult to find long-term data on
orthodontically treated individuals. Second, the ages used
in this study did not perfectly match up to those used by
Lemery.29 The oldest ages in the treated sample was 35
years, while the untreated sample was 50-60 years. Third,
no statistics were computed between the untreated and
treated samples due to the small sample size of the treated
subjects.
Surprisingly, there were no significant differences
found between Class I and Class II subjects. We chose the
sample based on molar relationship. However, if the sample
had been chosen based on cephalometric values (e.g., large
ANB difference), or profile assessment (e.g., very convex
profile or deficient mandible), we may have seen
significant differences between Class I and Class II
subjects. In addition, large differences were found between
75
males and females, who were incorporated when the sample
was divided into Class I and Class II subjects. The
interaction of males and females within the sample
categorized by Angle classification could have masked any
potential differences that might be present.
It must also be noted that at T1, extraction and nonextraction subjects were significantly different in the
horizontal dimension. Non-extraction subjects started out
larger and continued to be larger at the oldest ages. This
is a surprising finding. It is quite likely that the
practitioner considered characteristics of the casts and
cephalometric information as valuable in making the
extraction/non-extraction decision. He may also have placed
some value on the profile. In the present study it appears
that the result of the practitioner’s diagnostic
ministrations has strongly selected for faces whose
profiles have more or less horizontal development. This
curious finding, where the practitioner values “hard
tissue” relationships versus this study which values “softtissue” relationships, should be explored.
Subjects treated with extractions started out with
flatter, more vertical profiles and continued on that same
growth pattern. Treatment didn’t seem to change their more
vertical pattern of growth compared to those treated non-
76
extraction. It appears that treatment may have had an
immediate effect on the nose, lips, and chin, but over the
long-term, the facial pattern is the same.
77
Conclusions
On the basis of lateral cephalometric records from a
sample of 48 subjects examined pre-treatment, posttreatment, and long-term, the following conclusions were
drawn:
1.
Males are significantly larger in both the
anteroposterior and vertical dimensions at
nearly all time points. This was particularly
evident in the area of the lips in females.
2.
No significant differences were found between
Class I and Class II subjects at any time
point.
3.
Subjects treated non-extraction had softtissue profiles that had significantly larger
horizontal changes of the soft-tissue
landmarks. Surprisingly, no significant
differences were seen for any vertical
measures.
4.
Class II females treated with extractions had
soft-tissue profiles that had a distinct
vertical vector of growth in the area of the
lips and chin as compared to those females
treated non-extraction. Class I females
treated with extractions also had a vertical
78
vector of growth, but not as distinct as the
Class II females.
5.
Class II males treated with extractions had
soft-tissue profiles that had a more vertical
vector of growth, especially in the area of
the lips and chin.
When comparing these results of treated subjects
to those of untreated subjects found by Lemery,29
(Appendix A) the following conclusions were drawn:
1.
Orthodontic treatment appears to decrease the
fullness of the lips in females.
2.
Class I subjects who had orthodontic
treatment had soft-tissue lips and chin that
had a more horizontal vector of growth when
compared to untreated subjects.
3.
Class II subjects who had orthodontic
treatment had soft-tissue lips and chin that
had a more vertical vector of growth when
compared to untreated subjects.
4.
For Class I males and females, orthodontic
treatment appears to positively affect the
soft-tissue profile, especially in the area
of the chin. In the lip area, the effect of
treatment varied such that Class I males were
79
much improved while Class I females were
somewhat improved.
5.
For Class II males treatment does not really
alter the amount and direction of soft-tissue
change compared to untreated Class II males.
6.
For Class II treated females, the changes
that took place were not favorable; both the
chin and lips moved vertically contrary to
the untreated Class II females whose chin and
lips moved downward and forward.
Overall conclusions:
1.
Orthodontic treatment has both an immediate,
and a long-term effect on the soft-tissue
profile, especially for the chin and lips.
2.
The amount and direction of soft-tissue
growth varies with gender, Angle
classification, type of treatment rendered,
and time.
80
Acknowledgements
The authors would like to thank Dr. J.C. Boley for
allowing access to his long-term patient records.
The authors would like to thank Dr. Steven Lemery for
allowing access to his untreated patient results.
The authors would like to thank Brielle Killip for her
help with formatting.
81
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84
APPENDIX A:
Following are the tables (A.1-A.8) of untreated sample
from Lemery29 for comparison purposes.
Table A.1: Comparison of Males and Females at T129
Males
Females
Sig
Measure
t
V=Vertical; H=Horizontal
(2-tailed)
x ±SD(mm)
x ±SD(mm)
V-Nasion'
3.5 ± 2.2
3.1 ± 2.5
0.928
0.356
H-Nasion'
72.4 ± 3.0
69.9 ± 2.9
4.269
‡0.000
V-Rhinion'
19.7 ± 2.3
19.0 ± 2.2
1.411
0.161
H-Rhinion'
80.5 ± 3.0
78.4 ± 3.5
3.299
‡0.001
V-Superior Nasal Tip
33.3 ± 3.5
32.6 ± 3.6
1.018
0.311
H-Superior Nasal Tip
90.4 ± 3.3
88.2 ± 3.9
3.033
†0.003
V-Pronasale
38.3 ± 3.4
37.5 ± 3.6
1.221
0.225
H-Pronasale
91.9 ± 3.4
89.6 ± 4.0
3.029
†0.003
V-Inferior Nasal Tip
43.2 ± 3.5
42.1 ± 3.7
1.560
0.122
H-Inferior Nasal Tip
89.8 ± 3.6
87.6 ± 3.9
2.860
†0.005
V-Columella
46.9 ± 3.2
46.0 ± 3.6
1.309
0.194
H-Columella
85.3 ± 3.7
83.0 ± 3.7
3.044
†0.003
V-Subnasale
50.5 ± 3.0
50.5 ± 3.7
-0.033
0.974
H-Subnasale
79.7 ± 3.8
77.0 ± 3.6
3.630
‡0.000
V-Superior Labrale Sulcus
57.1 ± 3.5
56.5 ± 3.9
0.742
0.460
H-Superior Labrale Sulcus
78.9 ± 4.2
76.5 ± 3.7
3.021
†0.003
V-Labrale Superius
63.6 ± 3.9
62.3 ± 3.8
1.655
0.101
H-Labrale Superius
81.1 ± 4.3
77.9 ± 4.2
3.627
‡0.000
V-Stomion
70.4 ± 4.0
68.6 ± 3.7
2.230
*0.028
H-Stomion
74.4 ± 4.3
71.6 ± 4.4
3.230
†0.002
V-Labrale Inferius
79.4 ± 5.3
77.0 ± 4.3
2.470
*0.015
H-Labrale Inferius
76.0 ± 4.9
73.2 ± 4.6
2.834
†0.006
V-Labiomental Fold
84.9 ± 4.8
82.9 ± 4.4
2.104
0.038
H-Labiomental Fold
68.4 ± 5.2
66.7 ± 4.6
1.757
0.082
V-Pogonion'
95.1 ± 5.4
94.3 ± 5.1
0.781
0.437
H-Pogonion'
69.2 ± 5.5
67.5 ± 5.4
1.582
0.117
V-Gnathion'
103.8 ± 5.5
103.0 ± 5.4
0.671
0.504
H-Gnathion'
65.8 ± 6.0
63.9 ± 5.9
1.606
0.112
V-Menton'
110.0 ± 5.4
108.7 ± 5.4
1.157
0.250
H-Menton'
59.0 ± 6.3
56.8 ± 6.3
1.722
0.088
T1 ( x age=8.6 years)
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
85
Table A.2: Comparison of Males and Females at T229
Females
Males
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
T2 ( x age=14.1 years)
2.8
77.9
21.4
89.3
37.8
101.5
43.3
103.3
49.0
103.3
53.6
95.1
57.8
88.2
65.0
87.2
71.2
89.8
78.9
82.8
89.1
84.8
95.0
75.8
106.9
78.0
117.0
74.5
124.1
67.1
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.6
3.6
3.1
4.1
4.0
4.7
3.8
4.7
3.9
4.7
3.7
4.5
3.6
4.8
3.9
5.1
4.0
5.5
4.2
5.2
5.3
5.4
5.2
5.7
5.6
7.0
5.8
7.5
6.0
7.8
2.0
74.0
19.9
84.7
35.7
96.8
41.4
98.9
47.1
98.9
51.6
91.1
56.6
83.6
62.6
82.7
68.3
84.7
75.7
78.1
84.9
80.5
91.2
73.2
103.4
75.8
113.2
72.4
119.7
64.8
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.6
3.3
2.6
3.5
3.5
4.2
3.7
4.6
3.9
4.6
3.8
4.6
4.0
4.4
3.8
4.5
4.4
4.9
4.1
5.0
5.1
5.4
5.0
5.0
5.5
5.9
5.3
6.3
5.6
6.6
t
1.563
5.494
2.547
5.945
2.798
5.138
2.526
4.621
2.395
4.478
2.641
4.353
1.443
4.905
3.090
4.604
3.400
4.873
3.814
4.518
3.994
3.983
3.676
2.486
3.096
1.733
3.399
1.492
3.752
1.592
Sig
(2-tailed)
0.121
‡0.000
*0.013
‡0.000
†0.006
‡0.000
*0.013
‡0.000
*0.019
‡0.000
†0.010
‡0.000
0.152
‡0.000
†0.003
‡0.000
‡0.001
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
*0.015
†0.003
0.086
‡0.001
0.139
‡0.000
0.115
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
86
Table A.3: Comparison of Males and Females at T329
Females
Males
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
T3 ( x age=19.4 years)
2.8
81.7
22.3
94.9
40.2
108.4
46.1
110.2
52.4
107.5
56.8
100.5
60.8
92.7
68.6
91.1
74.9
94.2
83.0
86.7
93.6
89.6
100.6
80.4
113.5
83.6
124.3
80.3
132.0
72.7
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.3
2.9
3.2
3.2
4.9
3.7
4.6
3.8
4.4
4.0
4.2
3.9
4.7
3.8
4.9
4.1
4.8
4.2
4.7
4.5
5.3
4.7
5.6
5.7
5.4
6.8
5.8
7.5
6.1
8.1
2.5
74.9
20.9
86.4
37.4
99.0
42.9
100.7
48.8
98.2
53.0
91.7
58.1
83.7
64.3
82.9
69.9
85.0
77.3
78.4
87.1
81.2
93.5
74.2
106.5
76.5
116.0
72.9
122.5
65.2
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
3.0
3.4
2.7
3.6
3.7
4.4
3.7
4.7
3.8
4.8
3.6
4.5
3.6
4.5
3.8
4.6
4.1
5.0
4.1
5.3
5.0
5.7
4.7
5.6
5.6
6.5
5.5
6.9
5.4
7.1
t
0.688
10.485
2.319
12.537
3.219
11.483
3.813
11.029
4.347
10.365
4.776
10.340
3.190
10.619
4.897
9.435
5.496
9.929
6.346
8.367
6.262
7.964
6.775
5.447
6.313
5.276
7.294
5.070
8.144
4.854
Sig
(2-tailed)
0.493
‡0.000
*0.023
‡0.000
†0.002
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
†0.002
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
‡0.000
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
87
Table A.4: Comparison of Males and Females at T429
Females
Males
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
T4 ( x age=57.7 years)
2.7
82.7
23.5
97.9
43.4
110.7
49.6
112.1
55.9
109.2
59.6
101.5
61.7
92.0
71.4
91.3
80.8
92.5
85.9
88.4
93.6
91.8
103.1
84.5
117.4
88.3
127.9
84.9
135.2
77.6
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
3.9
3.0
4.0
3.5
5.0
3.9
4.3
4.0
4.7
4.4
4.3
4.3
4.3
4.0
4.8
4.5
5.2
5.1
5.6
4.8
6.5
5.6
8.0
6.1
6.6
7.6
6.7
8.3
6.9
8.6
4.1
78.6
23.3
90.1
40.4
102.3
46.4
103.6
52.1
100.7
56.3
94.7
60.1
84.7
66.9
83.5
75.3
85.0
82.2
80.0
89.9
82.5
96.8
77.2
110.8
79.4
120.6
75.1
125.9
66.4
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
3.1
3.7
2.6
3.3
2.2
4.0
2.6
4.0
2.7
4.2
2.9
4.5
2.8
4.2
3.1
4.2
3.7
4.5
4.2
4.5
4.6
5.0
5.3
5.2
5.6
4.8
6.4
5.5
6.1
6.7
t
-1.113
3.204
0.243
6.251
2.341
5.672
2.618
5.747
2.816
5.353
2.533
4.144
1.298
4.689
3.230
4.891
3.410
4.293
2.132
4.951
1.873
4.811
2.666
3.570
2.989
4.054
3.006
3.999
3.899
4.043
Sig
(2-tailed)
0.276
†0.005
0.810
‡0.000
*0.026
‡0.000
*0.014
‡0.000
†0.009
‡0.000
*0.017
‡0.001
0.205
‡0.000
†0.003
‡0.000
†0.002
‡0.000
*0.043
‡0.000
0.072
‡0.000
*0.013
†0.002
†0.006
‡0.000
†0.007
‡0.000
‡0.001
‡0.000
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
88
Table A.5: Comparison of Class I and Class II at T129
Class II
Class I
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
T1 ( x age=8.6 years)
3.1
71.7
19.4
79.9
33.1
89.6
37.9
91.0
42.5
89.1
46.5
84.3
50.7
78.3
56.8
77.5
62.5
79.4
69.3
73.4
77.7
75.4
84.0
68.9
94.6
70.3
103.5
67.2
109.6
60.4
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.4
3.1
2.2
3.4
3.5
3.8
3.4
4.0
3.4
4.0
3.1
4.0
3.1
4.1
3.1
4.4
3.6
5.0
3.6
5.0
4.3
5.5
4.4
5.6
4.7
5.9
4.9
6.1
5.1
6.2
3.6
70.5
19.2
79.1
32.5
89.1
37.6
90.5
42.4
88.5
46.0
84.2
50.0
78.6
56.5
78.1
63.4
79.7
69.6
72.8
78.4
74.1
83.7
66.5
94.7
66.6
103.3
62.8
109.1
55.6
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.4
3.1
2.4
3.4
3.7
3.6
3.7
3.6
3.9
3.6
3.8
3.7
3.7
3.7
4.4
3.7
4.4
4.1
4.5
4.1
5.6
4.2
5.2
4.1
6.0
4.3
6.1
4.9
6.0
5.5
t
-0.916
1.784
0.293
1.148
0.804
0.661
0.443
0.611
0.217
0.668
0.637
0.160
0.860
-0.421
0.375
-0.688
-1.023
-0.339
-0.379
0.652
-0.681
1.302
0.300
2.340
-0.089
3.469
0.154
3.815
0.470
3.912
Sig
(2-tailed)
0.362
0.078
0.771
0.254
0.424
0.510
0.659
0.543
0.829
0.506
0.526
0.873
0.392
0.675
0.708
0.493
0.309
0.735
0.706
0.516
0.498
0.196
0.765
*0.022
0.929
‡0.001
0.878
‡0.000
0.640
‡0.000
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
89
Table A.6: Comparison of Class I and Class II at T229
Class I
Class II
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
T2 ( x age=14.1 years)
2.5
76.1
20.6
86.9
36.2
98.6
41.6
100.5
47.3
98.5
51.9
92.6
56.5
85.2
63.0
84.4
68.7
86.7
76.2
80.5
85.4
83.1
91.8
75.7
103.8
78.6
113.9
75.4
121.0
67.7
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.7
3.7
2.5
3.9
3.6
4.7
3.6
5.0
3.6
5.1
3.5
5.0
3.8
4.9
3.7
5.2
4.1
5.9
4.2
5.5
5.1
5.9
5.1
5.7
5.4
6.5
5.3
6.7
5.6
6.7
2.1
75.6
20.6
87.2
36.8
99.8
42.6
101.8
48.4
99.5
52.8
93.9
57.5
87.0
64.2
85.9
70.6
88.2
78.3
80.8
88.5
82.7
94.5
73.7
106.4
75.8
116.2
72.1
122.9
64.7
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.5
4.1
3.1
4.8
4.1
5.1
4.0
5.1
4.2
4.9
4.1
4.8
3.8
5.2
4.3
5.3
4.6
5.7
4.6
5.5
5.8
5.5
5.8
5.0
6.1
5.6
6.4
6.1
6.9
6.7
t
0.857
0.633
-0.062
-0.316
-0.726
-1.140
-1.310
-1.279
-1.414
-1.009
-1.078
-1.311
-1.195
-1.722
-1.356
-1.423
-2.050
-1.204
-2.326
-0.271
-2.733
0.341
-2.340
1.786
-2.126
2.215
-1.856
2.430
-1.496
2.151
Sig
(2-tailed)
0.394
0.528
0.951
0.753
0.470
0.257
0.194
0.204
0.161
0.316
0.284
0.193
0.235
0.089
0.179
0.158
*0.043
0.232
0.022
0.787
†0.008
0.734
*0.022
*0.078
*0.036
*0.029
0.067
*0.017
0.139
*0.034
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
90
Table A.7: Comparison of Class I and Class II at T329
Class II
Class I
Measure
t
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
T3 ( x age=19.4 years)
2.8
78.9
21.5
91.1
38.4
104.0
43.9
105.8
50.0
103.3
54.4
96.4
59.0
88.3
65.9
87.2
71.7
89.9
79.5
83.2
89.4
86.4
96.3
79.0
109.3
82.5
119.5
79.4
126.4
72.1
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.4
4.7
2.8
5.3
4.8
6.1
4.4
6.3
4.4
6.4
3.9
6.2
3.7
6.1
4.2
6.0
4.6
6.5
4.9
6.5
5.5
6.9
5.6
6.5
6.0
7.3
6.4
7.7
6.8
8.2
2.3 ±
77.7 ±
21.4 ±
90.2 ±
39.0 ±
103.5 ±
44.8 ±
105.2 ±
50.8 ±
102.6 ±
55.1 ±
96.1 ±
59.7 ±
88.4 ±
67.0 ±
87.1 ±
73.0 ±
89.5 ±
80.7 ±
82.4 ±
91.1 ±
85.0 ±
97.9 ±
76.1 ±
110.6 ±
78.2 ±
120.7 ±
74.6 ±
128.0 ±
66.8 ±
2.8
4.5
3.1
5.5
4.3
6.2
4.4
6.4
4.5
6.4
4.7
6.0
5.0
6.1
5.7
6.0
5.6
6.6
5.7
6.3
6.5
6.3
7.1
5.8
7.1
7.0
7.7
7.4
8.2
7.4
0.986
1.185
0.160
0.799
-0.655
0.435
-0.902
0.460
-0.794
0.515
-0.716
0.270
-0.781
-0.060
-1.017
0.039
-1.167
0.305
-1.094
0.624
-1.308
1.078
-1.221
2.324
-0.945
2.902
-0.813
3.089
-1.001
3.225
Sig
(2-tailed)
0.327
0.239
0.873
0.426
0.514
0.664
0.370
0.647
0.430
0.608
0.476
0.788
0.437
0.952
0.312
0.969
0.247
0.761
0.277
0.534
0.194
0.284
0.226
*0.022
0.348
†0.005
0.419
†0.003
0.320
†0.002
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
91
Table A.8: Comparison of Class I and Class II at T429
Class II
Class I
Measure
V=Vertical; H=Horizontal
x ±SD(mm)
x ±SD(mm)
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
2.9
3.5
3.1
4.5
5.1
5.5
4.4
5.6
4.8
6.0
4.3
5.4
4.1
5.2
5.3
5.4
5.8
6.0
6.2
6.1
6.5
7.2
8.0
7.4
6.9
8.7
7.4
9.8
8.2
9.5
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
4.3
4.3
4.0
6.0
3.5
5.5
3.5
5.7
4.1
5.8
4.0
5.2
3.6
4.9
4.3
5.6
4.9
5.6
4.7
5.6
6.1
6.2
8.3
5.3
7.5
6.9
8.1
7.2
8.3
8.5
1.451
0.224
1.449
0.157
0.463
-0.703
0.862
-0.693
0.974
-0.591
0.856
-0.465
1.107
-0.860
0.912
-1.133
0.853
-1.403
0.304
-0.970
0.155
-1.028
-0.313
-0.749
-0.181
-0.641
-0.123
-0.518
-0.117
-0.192
Sig
(2-tailed)
V-Nasion'
H-Nasion'
V-Rhinion'
H-Rhinion'
V-Superior Nasal Tip
H-Superior Nasal Tip
V-Pronasale
H-Pronasale
V-Inferior Nasal Tip
H-Inferior Nasal Tip
V-Columella
H-Columella
V-Subnasale
H-Subnasale
V-Superior Labrale Sulcus
H-Superior Labrale Sulcus
V-Labrale Superius
H-Labrale Superius
V-Stomion
H-Stomion
V-Labrale Inferius
H-Labrale Inferius
V-Labiomental Fold
H-Labiomental Fold
V-Pogonion'
H-Pogonion'
V-Gnathion'
H-Gnathion'
V-Menton'
H-Menton'
3.7
81.5
23.9
95.5
42.4
107.5
48.8
108.9
55.0
106.0
58.7
99.1
61.5
89.1
70.3
88.0
79.5
89.0
84.7
84.9
92.5
87.9
100.6
81.7
114.7
84.8
125.0
81.2
131.7
73.9
T4 ( x age=57.7 years)
* denotes p≤0.05; † denotes p≤0.01; ‡ denotes p≤0.001
92
1.6
81.2
21.9
95.1
41.7
109.0
47.5
110.3
53.4
107.4
57.3
100.0
59.9
90.7
68.7
90.4
77.7
92.0
84.1
87.0
92.1
90.5
101.6
83.5
115.2
86.6
125.4
82.8
132.0
74.5
t
0.167
0.825
0.165
0.877
0.647
0.490
0.397
0.496
0.340
0.561
0.401
0.647
0.279
0.399
0.370
0.271
0.402
0.174
0.764
0.342
0.878
0.314
0.757
0.460
0.858
0.527
0.904
0.609
0.908
0.849
VITA AUCTORIS
Katherine (Kate) Gielow was born February 16, 1979 in
St. Louis, Missouri to Ken and Sherry Gielow. She was
raised in Herculaneum, Missouri with her twin sisters, Sue
and Liz. After graduating from Herculaneum High School in
1997, she attended Washington University in St. Louis where
she played collegiate volleyball. In 2001, she graduated
with a dual degree in Biology and Economics. After college,
she continued her higher education at Southern Illinois
University School of Dental Medicine where she received her
D.M.D. (Doctor of Dental Medicine) in 2005. She was then
accepted into the orthodontic program at St. Louis
University where she will graduate in January 2008. She
plans to open her own practice in Hillsboro, Missouri.
Kate married Alan Barnette December 15, 2002 in St.
Louis, Missouri. They have one daughter, Elizabeth, who was
born during her residency in July 2007.
93