ORIGINAL ARTICLE

Effect of nonextraction and extraction

orthodontic treatments on smile esthetics
for different malocclusions
Hsin-Chung Cheng and Yi-Chun Wang
Taipei, Taiwan

Introduction: Smile esthetics is a critical factor for evaluating orthodontic treatment outcomes. In this study, we eval-
uated the differences in esthetic perceptions and smile variables between extraction and nonextraction treatments for
different malocclusions. Methods: Ninety participants were divided into 3 groups according to their pretreatment over-
jet (group I, 0-4 mm; group II, .4 mm; group III,\0 mm), with 15 extraction participants and 15 nonextraction partic-
ipants in each group. Posttreatment frontal smiling photographs were evaluated by 30 raters (10 orthodontists, 10
general dentists, 10 laypeople), and 9 smile variables were measured. Results: Smile perception for the group II
extraction subjects was higher than for the nonextraction subjects by the orthodontists and general dentists. Regard-
less of the type of treatment, group III subjects were rated lower than those in groups I and II. The arch form index,
maxillary incisor show, and smile arc were greater in the extraction participants. In multiple regression analysis, non-
extraction and group III correlated negatively with the esthetic score. Maxillary incisor show, tooth number display, and
buccal corridor ratio correlated positively with the esthetic score. Conclusions: Group II extraction subjects were
rated higher than the nonextraction subjects by dental professionals. A smile with greater maxillary incisor show,
number of displayed teeth, and buccal corridor ratio was considered more esthetic. (Am J Orthod Dentofacial
Orthop 2018;153:81-6)

S
mile esthetics has always been the focus of ortho- comprehensive search for eligible studies, a systematic
dontic treatment. It has become a main reason application of eligibility criteria, and a rigorous analytical
that patients seek orthodontic treatment,1 and approach, we statistically combined the data from
patients now evaluate their treatment outcomes not relevant studies. Results of our meta-analysis showed no
only by the occlusion and alignment but also by the difference between extraction and nonextraction treat-
smile esthetics. ments.10 A systemic review also concluded that 4 premolar
In orthodontics, tooth extractions are a common extractions and nonextraction treatment have no predict-
treatment modality. Previous studies mainly focused able effect on the overall esthetic assessment of the smile
on lateral profile changes regarding tooth extractions because individual variability could influence the smile
and concluded that extraction treatment could result perception as esthetically pleasing or not.11
in an improved lateral profile for many patients with Because previous studies regarding frontal smile es-
some combination of crowding and protrusion.2,3 thetics pooled all participants for analysis without
For the frontal smile esthetics, authors used patients’ considering the large variations among patients, they
posttreatment frontal smiling photos for evaluation and could not determine whether extraction treatments
found no significant differences in the esthetic scores be- were more satisfactory than nonextraction treatments
tween extraction and nonextraction groups.4-9 Through a (or vice versa) in terms of smile esthetics.
The purpose of this study was to compare extraction
From the School of Dentistry, College of Oral Medicine, Taipei Medical Univer- and nonextraction treatments on smile esthetics for
sity; Orthodontic Division, Department of Dentistry, Taipei Medical University different malocclusions including subjective esthetic
Hospital, Taipei, Taiwan.
perceptions by panel raters and objectively by measuring
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. the smile variables.
Address correspondence to: Hsin-Chung Cheng, School of Dentistry, College of
Oral Medicine, Taipei Medical University, No. 250, Wuxing Street, Xinyi District,
Taipei City 110, Taiwan; e-mail, g4808@tmu.edu.tw.
MATERIAL AND METHODS
Submitted, December 2016; revised and accepted, May 2017. A total of 90 participants were randomly selected from
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved. a sample of 600 patients organized in an Excel spread-
http://dx.doi.org/10.1016/j.ajodo.2017.05.033 sheet (Microsoft, Redmond, Wash) from the orthodontic
81
82 Cheng and Wang

department of our hospital in Taipei, Taiwan. This study Nine smile variables were measured from the post-
was approved by the institutional review board of Taipei treatment frontal smiling photographs by using the
Medical University Hospital (No. 201503035). The inclu- linear measurement tool in Photoshop (Fig). The tool
sion criteria for the participants were (1) all permanent rounded the measurements to the nearest 0.01 mm.
dentition, (2) completed orthodontic treatment with fixed Because of the differences in the magnification of the
appliances from 2011 to 2014, and (3) a complete set of photographs, exact linear measurements could not be
posttreatment records, including study models, pano- obtained. Therefore, to minimize bias, smile variables
ramic radiographs, and intraoral and extraoral photo- except tooth number display and midline were measured
graphs. Participants with a large skeletal discrepancy for as ratios.
which surgical orthodontic treatment might be indicated Seven smile variables were ratios (Fig): (1) smile arc
were excluded from the study. To investigate the differ- ratio, distance of the maxillary incisor edge to the inter-
ence between extraction and nonextraction for different canine connecting line divided by the distance of the
malocclusions, the participants were further divided into lower lip to the intercanine connecting line; (2) maxillary
3 groups according to their pretreatment overjet: group incisor show, distance of the maxillary incisal edge to the
I (0-4 mm), group II (.4 mm), and group III (\0 mm). upper lip divided by the incisor width; (3) mandibular
Each group contained 30 participants who received teeth exposure, visible mandibular incisor length divided
extraction (n 5 15) or nonextraction (n 5 15) treatment. by the mandibular incisor width; (4) arch form index, in-
The age and sex distributions were the same in both the tercanine width divided by intermolar width; (5) buccal
extraction and nonextraction subjects in all groups. corridor ratio, intercommissure width divided by interca-
Although the total treatment duration was longer for nine width; (6) smile index, intercommissure width
the extraction than the nonextraction subjects, this differ- divided by the interlabial gap; and (7) interlabial gap, in-
ence was significant only in groups I and III. terlabial gap divided by intercanine width.
Each participant's posttreatment frontal smiling Two smile variables were not ratios: (1) midline, up-
photograph was taken using a digital camera (550D; per and lower dental midlines (on, 1; off, 0) and (2) tooth
Canon,) and stored in JPEG format. According to the number display: exposed maxillary teeth.
standard operation procedure of our department, a
well-trained photographic assistant instructed the par- Statistical analysis
ticipants to say “7” or “cheese” while holding their heads Statistical analyses were performed using the R Data
in a natural position. Photoshop software (Adobe Sys- Analysis and Guiding System (Chinese Association of R
tems, San Jose, Calif) was used to manage the photo- Software Research and Application, Taiwan). We
graphs, which were cropped to show only the perioral randomly assigned the 30 participants in each group
area and converted to black and white images to mini- into 2 treatments (each treatment had 150 measure-
mize the influence of other facial characteristics and ments), which provided 87% power to detect a differ-
skin color. PowerPoint (Microsoft) was used to show ence between means at a significance level of 5% by
the photographs to the raters in a random order. using a 2-sided t test. A power test was performed to
Raters, comprising 10 laypeople, 10 general dentists, ensure an adequate sample size. A 2-sample t test was
and 10 orthodontists, performed subjective evaluations used to compare the esthetic scores and smile variables
of the smile esthetics. The ages of the raters were be- between the extraction and nonextraction subjects in
tween 30 and 50 years, and the general dentists and or- each group. One-way analysis of variance was used to
thodontists had more than 5 years of clinical experience. compare smile perceptions among the 3 types of raters.
Laypeople were randomly contacted in the mass rapid Multiple regression analysis was used to evaluate the ef-
transit station. The raters had the same age and sex dis- fects of tooth extraction treatment and groups on the
tributions, and no difference was noted in the years of smile esthetic score and to identify whether any variables
clinical experience between the general dentists and or- influenced the smile esthetic scores. The level of signif-
thodontists. icance was established as P \0.05 for all statistical tests.
Each rater used a visual analog scale to score the
smile esthetics of each photo. The scale was created on
a 100-mm uninterrupted line anchored at 0 on the left RESULTS
(very unattractive) and 10 on the right (very attractive). Table I shows the mean esthetic scores of the extrac-
The raters made their decisions independently, with no tion and nonextraction subjects stratified by group. In
information regarding the participants. They were al- group II, extraction was rated higher than nonextraction.
lowed to review the slides and revise their scores until No differences were observed in groups I and III. More-
they reached a final decision. over, regardless of the type of treatment, the group III

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Cheng and Wang 83

Fig. Smile variables: A, smile arc ratio (a, distance of maxillary incisor edge to intercanine connecting
line; b, distance of lower lip to the intercanine connecting line); B, maxillary incisor show (c, distance of
maxillary incisal edge to upper lip; d, maxillary incisor width); C, mandibular teeth exposure (e, visible
mandibular incisor length; f, mandibular incisor width); D, arch form index (g, intercanine width; h, inter-
molar width); E, buccal corridor ratio (i, intercommissure width; j, intercanine width); F, smile index (i,
intercommissure width; k, interlabial gap); G, interlabial gap (k, interlabial gap; j, intercanine width).

participants received significantly lower ratings than did

Table I. Esthetic scores of extraction and nonextrac-
the groups I and II participants.
tion stratified by group
The esthetic perceptions of the different raters were
compared (Table II). Group II extraction subjects were Extraction Nonextraction
rated higher than the nonextraction subjects by ortho- Mean 6 SD Mean 6 SD P value
dontists and general dentists. Therefore, the total Group I 53.19 6 16.58 52.14 6 17.25 0.35
esthetic score of extraction was higher. In all groups, Group II 53.69 6 16.73 48.81 6 17.90 \0.001*
the ratings by laypeople showed no difference between Group III 48.90 6 16.30 47.76 6 16.67 0.331
extraction and nonextraction.
*P \0.001.
Table III shows the smile variables of extraction and
nonextraction stratified by group. In group I, smile arc,
maxillary incisor show, and arch form index were greater
in extraction subjects. In group III, arch form index was the laypeople. For the participants who had extraction
greater in the extraction group. In group II, no difference treatment, tooth number display correlated positively
was observed between extraction and nonextraction. A with esthetic scores by all raters, and mandibular teeth
comparison of the smile variables of the 3 groups exposure correlated negatively with esthetic scores by
showed that maxillary incisor show was significantly the laypeople. For the participants who had nonextrac-
less in group III than in group II, and lower lip exposure tion treatment, buccal corridor ratio correlated positively
was significantly greater in group III than in group II. with esthetic scores by the general dentists and
Multiple regression analysis was used to evaluate the laypeople.
effect of treatments and groups on the smile esthetic
scores (Table IV). Nonextraction and group III correlated DISCUSSION
negatively with the smile esthetic score. This study focused on frontal smile esthetics. One
Table V shows the results for the multiple regression important factor that influences frontal smile esthetics
analysis of the esthetic scores and smile variables strati- is different overjets of anterior teeth. The participants
fied by rater type. For all participants, maxillary incisor in this study were divided into 3 groups according to
show correlated positively with esthetic scores by the or- their pretreatment overjet. Instead of the ANB angle,
thodontists; tooth number display and maxillary incisor overjet was used for patient classification because (1)
show correlated positively with esthetic scores by the the ANB angle of cephalometric measurements may be
general dentists; and buccal corridor ratio and maxillary influenced by the diversity of individual cranial bases,
incisor show correlated positively with esthetic scores by and (2) the skeletal measurements of cephalograms do

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Table II. Esthetic perceptions of the raters stratified by group

Orthodontists General dentists Laypeople

Extraction Nonextraction Extraction Nonextraction Extraction Nonextraction

Mean 6 SD Mean 6 SD P value Mean 6 SD Mean 6 SD P value Mean 6 SD Mean 6 SD P value

Group I 56.07 6 15.52 53.85 6 14.58 0.20 52.92 6 13.87 52.08 6 14.62 0.61 50.59 6 19.49 50.48 6 21.56 0.96
Group II 56.69 6 14.42 49.73 6 14.14 \0.001y 52.29 6 13.56 47.71 6 13.96 0.004* 52.1 6 20.93 49 6 20.10 0.19
Group III 50.47 6 16.59 50.25 6 13.87 0.90 49.65 6 16.11 46.60 6 14.50 0.90 46.56 6 20.55 46.41 6 20.61 0.95

*P \0.01; yP \0.001.

Table III. Smile variables of extraction and nonextraction stratified by group

Group I Group II Group III

Extraction No-ext Extraction Nonextraction Extraction Nonextraction

Mean 6 SD Mean 6 SD P value Mean 6 SD Mean 6 SD P value Mean 6 SD Mean 6 SD P value

Smile arc 0.52 6 0.27 0.29 6 0.25 0.01* 0.53 6 0.33 0.5 6 0.34 0.75 0.42 6 0.28 0.35 6 0.36 0.14
Tooth number 8.53 6 1.60 8.53 6 0.92 0.78 8.67 6 1.45 8.67 6 1.80 0.91 7.87 6 1.77 8.13 6 1.77 0.64
Maxillary incisor 1.01 6 0.32 0.76 6 0.29 0.04* 0.99 6 0.26 0.93 6 0.31 0.53 0.81 6 0.25 0.69 6 0.24 0.15
Midline 0.60 6 0.51 0.73 6 0.46 0.45 0.80 6 0.41 0.67 6 0.49 0.42 0.73 6 0.46 0.73 6 0.46 1.00
Buccal corridor 1.54 6 0.14 1.62 6 0.15 0.13 1.68 6 0.18 1.68 6 0.12 0.79 1.61 6 0.12 1.58 6 0.14 0.52
Smile index 5.70 6 1.09 5.97 6 1.91 0.98 6.37 6 1.26 6.51 6 2.44 0.68 6.54 6 3.25 6.91 6 2.15 0.30
Arch form 0.83 6 0.04 0.76 6 0.02 \0.001y 0.81 6 0.05 0.78 6 0.04 0.06 0.82 6 0.05 0.75 6 0.05 \0.001y
Mandibular teeth 0.41 6 0.24 0.69 6 0.40 0.06 0.37 6 0.35 0.42 6 0.39 0.80 0.71 6 0.42 0.57 6 0.41 0.37
Interlabial gap 0.28 6 0.07 0.29 6 0.08 0.43 0.27 6 0.06 0.29 6 0.09 0.71 0.28 6 0.09 0.25 6 0.09 0.29

*P \0.05; yP \0.001.

Peck et al12 indicated that dental professionals and

Table IV. Multiple regression analysis of the esthetic
laypeople judge facial esthetics differently because den-
scores for nonextraction treatment and group III
tists are trained to observe features that are not obvious
Estimate SD P value to the general public. In this study, the smile ratings
Nonextraction 2.358 0.652 \0.001* given by laypeople did not differ significantly between
Group III 4.339 0.798 \0.001* the extraction and nonextraction subjects in any group.
*P \0.001. This result is consistent with that of Ghaffar and Fida.5
The arch form index, measured as the ratio of inter-
canine width to intermolar width, was significantly
not always reflect the real condition of a dental occlu- higher in the extraction treatment of groups I and III.
sion. Closure of the extraction space often results in mesial
Previous studies comparing smile esthetics between movement of the molars into a narrower arch and distal
extraction and nonextraction reported no differences movement of the canines into a wider arch, causing the
between the 2 treatments.4-9 Because the participants ratio to be greater. Maximum anchorage is often
in the study were pooled for the analysis, the effect of required for group II extraction treatment with little or
the treatment for different malocclusions could not be no molar mesial movement; this might be why no differ-
investigated. We divided the participants into 3 ence was observed in the arch form index between
groups. Results show that for group II, the extraction and nonextraction in group II. Moreover,
orthodontists and general dentists rated extraction although the arch form index was higher in extraction
significantly higher than nonextraction. Regardless of than nonextraction in groups I and III, no difference
the treatment types, group III had significantly lower was observed in the buccal corridor ratio. This result is
esthetic scores than did groups I and II. This result may consistent with a previous study that reported that
be due to less maxillary incisor show and greater although significant arch width changes were likely to
mandibular teeth exposure resulting from the dental occur, no clinically relevant effects on the buccal
compensation for group III. corridor ratio were identified.13

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Cheng and Wang 85

no difference in the tooth number display between extrac-

Table V. Multiple regression analysis of smile vari-
tion and nonextraction groups. However, smiles that
ables and esthetic scores stratified by rater
display more teeth are considered to be more esthetic.
Estimate SD P value In the nonextraction participants, the buccal corridor
All raters ratio correlated positively with the esthetic scores by all
Total raters except for orthodontists, indicating that a full smile
Maxillary incisor 6.51 2.30 0.006y
is unnatural and less attractive to general dentists and
Buccal corridor 10.48 4.56 0.02*
Extraction laypeople. Orthodontists reported no esthetic preference
Tooth number 2.4 0.60 \0.001z in the buccal corridor ratios between the 2 treatments;
Nonextraction this is consistent with the results of previous studies.16,17
Buccal corridor 15.62 6.38 0.02* There were some limitations in this study. First,
Orthodontists
although the participants were divided into 3 groups ac-
Total
Maxillary incisor 7.43 2.31 0.004y cording to their pretreatment overjet, there were still in-
Extraction dividual variations such as differences in space
Tooth number 2.48 0.67 \0.001z deficiency among each group. Second, smile esthetics
Nonextraction is dynamic and difficult to measure; there is no standard
General dentists
method for evaluation. Third, although the cropped
Total
Maxillary incisor 4.77 2.17 0.03* photographs reduced the possibility of grading smiles
Tooth number 1.14 0.44 0.01* according to criteria that were not under orthodontic
Extraction control, smiles are judged according to the balance of
Tooth number 2.27 0.55 \0.001z the whole face in actual life.18 For further research, it
Nonextraction
is better to achieve equal baseline characteristics of par-
Buccal corridor 12.69 5.56 0.03*
Laypeople ticipants, and digital videos for 3-dimensional views of
Total the smiles may be helpful to obtain reproducible and
Maxillary incisor 6.67 2.94 0.03* comprehensive smiling photographs.
Buccal corridor 19.71 5.83 0.001z The results of this study indicate that smiles with
Extraction
greater maxillary incisor show, tooth number display,
Tooth number 2.74 0.73 \0.001z
Mandibular teeth 7.81 2.93 0.01* and buccal corridor ratio are more esthetic. In addition,
Nonextraction extraction treatments tend to retrude the lips and retract
Buccal corridor 23.32 9.11 0.01* the incisors, increasing the maxillary incisor show,
*P \0.05; yP \0.01; zP \0.001.
whereas nonextraction treatments tend to flare the inci-
sors, flatten the smile arc, and protrude the lips.

The maxillary incisor show and smile arc were signif- CONCLUSIONS
icantly smaller in group I nonextraction subjects. Nonex-
traction orthodontic treatment by means of expansion 1. The esthetic scores by dental professionals were
of the dental arch with increased maxillary incisor torque higher in extraction than nonextraction in group
might flatten the smile arc and reduce the incisor display. II. Laypeople had no esthetic preference regarding
Nonextraction treatment and group III correlated the type of treatment.
negatively with the smile esthetic scores, implying that 2. The smile esthetic score of group III was signifi-
nonextraction treatment and group III participants cantly lower than the scores for groups I and II
received lower esthetic scores. For all participants, the because of the smaller maxillary incisor show and
maxillary incisor show correlated positively with the greater mandibular teeth exposure.
esthetic scores by all raters, indicating that a greater 3. Regarding the smile variables, the arch form index
maxillary incisor show results in a more esthetic smile. was higher in the groups I and III extraction partic-
This finding is similar to previous studies that have ipants. The smile arc and maxillary incisor show
shown that a smile with a full incisor display is deemed were greater in the group I extraction subjects.
more youthful and esthetic.14,15 4. The maxillary incisor show correlated positively with
Although the participants in extraction and nonextrac- the esthetic score in all participants. The tooth num-
tion displayed an equal number of teeth in all groups when ber display correlated positively with the esthetic
smiling, the numbers of tooth display correlated positively score in the extraction participants. The buccal
with the esthetic scores for extraction treatment. This corridor ratio correlated positively with the esthetic
result is similar to that of Kim and Gianelly,7 who reported score in the nonextraction participants.

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