ORIGINAL ARTICLE

Long-term profile attractiveness of

patients with Class I and II malocclusion
treated with and without extractions: A
35-year follow-up
Gabriel Bravo Vallejo,a Gabriela de Dome ^nico Alcaraz Ros,a Renan Morais Peloso,a
Caroline Martins Gambardela-Tkacz,a Paula Cotrin,b Karina Maria Salvatore Freitas,b and Marcos Roberto de
Freitasa
Bauru, S~ao Paulo, and Maringa, Parana, Brazil

Introduction: The objective of this study was to compare the profile attractiveness in subjects treated with and
without extractions after the long-term 35-year follow-up, according to laypeople, dentists, and orthodontists.
Methods: A total of 40 patients with Class I and II malocclusion were divided into 2 groups, according to the treat-
ment protocol: extraction (E) group, extractions of 4 premolars (n 5 24), with mean pretreatment (T1), posttreat-
ment (T2), and long-term posttreatment (T3) ages of 13.13, 15.50 and 49.56 years, respectively. The mean
treatment time (T2
T1) was 2.37 years, and the long-term follow-up (T3
T2) was 34.19. Nonextraction
(NE) group (n 5 16), with mean ages at T1, T2, and T3 of 13.21, 15.07, and 50.32 years, respectively. The
mean (T2
T1) was 1.86 years, and the (T3
T2) was 35.25 years. Lateral cephalograms were used to
perform profile facial silhouettes, and an online evaluation was performed by 72 laypeople, 63 dentists, and
65 orthodontists, rating the attractiveness from 1 (least attractive) to 10 (most attractive). The intragroup
comparison was performed with the repeated measures analysis of variance and Tukey tests. Intergroup
comparison was performed with t tests, 1-way analysis of variance, and Tukey tests. Results: The E group
had a longer treatment time than that of the NE group. In the pretreatment, posttreatment, and long-term
posttreatment stages, the E and NE groups showed similar profile attractiveness. Laypersons and dentists
were more critical than orthodontists. Conclusions: At long-term posttreatment follow-up, profile
attractiveness was similar in patients treated with and without extractions. (Am J Orthod Dentofacial Orthop
2023;-:---)

T
he human face plays a pivotal role in assessing relationship, often motivating patients to seek care.2-4
attractiveness and physical beauty.1 Esthetic facial However, assessing the harmony and beauty of a face,
balance is a primary goal in orthodontic treatment, which is a subjective characteristic, is personal and
alongside well-aligned teeth and an excellent occlusal complex to measure. Furthermore, a harmonious face
is not necessarily pleasant.5,6
a The extraction of teeth for malocclusion treatment
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo,
Bauru, S~ao Paulo, Brazil. has been a subject of significant debate. Extractions
b
Department of Orthodontics, Inga University Center UNINGA,  Maringa, Parana, were a prevalent approach a century ago and are still em-
Brazil.
ployed today to achieve facial harmony.7-9 The long-
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. term stability of extraction treatments was demon-
This study was financed by the Coordenaç~ao de Aperfeiçoamento de Pessoal de strated in subjects with Class I and II malocclusions,10,11
Nıvel Superior, Brasil (CAPES) - Finance Code 001.
in addition to the efficacy of treatment with and without
This article is based on the research submitted by Gabriel Bravo Vallejo in partial
fulfillment of the requirements for the degree of MSc in Orthodontics at Bauru extractions.11,12
Dental School, University of S~ao Paulo. Depending on the treatment chosen, there is a concern
Address correspondence to: Gabriel Bravo Vallejo, Department of Orthodontics,
about the effects of orthodontic treatment on the facial
Bauru Dental School, University of S~ao Paulo, Alameda Octavio Pinheiro Brisolla
9-75, Bauru, S~ao Paulo 17012-901, Brazil; e-mail, g.e.b.v.1994@gmail.com. profile and attractiveness. Some researchers have
Submitted, June 2023; revised and accepted, November 2023. analyzed the effect of orthodontic treatment with and
0889-5406/$36.00
without extractions on the profile13-17 with
Ó 2024 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2023.11.009 controversial results. Some studies suggested that

1
2 Bravo Vallejo et al

extraction of premolars flattens the facial profile, whereas

Table I. Intergroup comparability of the pretreatment,
others claimed that with proper diagnostic criteria, it
posttreatment, and long-term posttreatment ages,
would not adversely affect it.13,15,17 In contrast, there is
treatment time, time of long-term posttreatment eval-
a claim that this finding lacks evidence in most patients.16
uation, retention time, sex distribution, and type of
Long-term studies following treatments with and
malocclusion (independent t and chi-square tests)
without extractions have not found significant cephalo-
metric or esthetic differences 15 years after treatment. E group (n 5 NE group (n 5
However, there is a lack of information regarding the Variables 24) 16) P value
outcomes beyond a 35-year treatment span.14,18 Some Pretreatment age (y) 13.13 6 2.21 13.21 6 0.83 0.893§
Posttreatment age (y) 15.50 6 2.34 15.07 6 1.16 0.498§
researchers suggest a positive correlation between the Long-term posttreatment 49.56 6 6.45 50.32 6 6.05 0.710§
change in the position of the lips and the change in age (y)
the profile.15,19 Other demonstrated changes in growth Treatment time (y) 2.37 6 0.63 1.86 6 0.83 0.032*,§
in late adolescence, aging in the facial profile, such as Long-term posttreatment 34.06 6 5.17 35.25 6 6.11 0.558§
the closing of the nasolabial angle, lip retrusion, and time (y)
Retention time (y) 2.65 6 1.48 2.26 6 1.18 0.387§
an increase in the soft tissue of the chin.20-22 However, Sexy 0.787||
extractions do not negatively affect the facial soft- Females 16 10
tissue profile over time.23 Males 8 6
According to the literature, the controversy of the re- Malocclusion typez 0.0602||
sults on the influence of tooth extractions and attractive- Class I 11 6
Class II 13 10
ness can be seen because soft tissues are related to beauty
ideals and are influenced by aging. It is essential to Note. Values are presented as mean 6 standard deviation.
y 2
c 5 0.07; degrees of freedom 5 1; zc2 5 0.27; degrees of
observe how they are influenced by orthodontic mecha- freedom 5 1; *Statistically significant for p \0.05; §Independent t
notherapy in the short and long term. No previous study test; ||Chi-square test.
compared long-term profile attractiveness with extraction
and nonextraction mechanotherapy after 35 years. There-
fore, this study aimed to compare long-term profile appliance (Hawley plate) worn for 1 year, mandibular
attractiveness in subjects treated with and without extrac- fixed canine-to-canine retainers worn for at least 1
tions, according to laypeople, dentists, and orthodontists, year, and a maximum of 3 years after treatment, without
after a long-term follow-up of 35 years. retention at the time of follow-up.
The sample comprised lateral cephalograms of 40 sub-
MATERIAL AND METHODS jects obtained at 3 different time points: pretreatment
This retrospective study was approved by the (T1), posttreatment (T2), and long-term follow-up (T3).
Research Ethics Committee of the Bauru Dental School, The sample was divided into 2 groups according to
University of S~ao Paulo, Bauru, SP, Brazil (protocol no. the protocol orthodontic treatment: the extraction (E)
CAAE: 51079121.1.0000.5417). group comprised 24 subjects (16 females and 8 males).
The sample size calculation was based on an a signif- A total of 11 presented Class I malocclusion, whereas
icance level of 5% and a b of 20% to achieve 80% test 13 presented Class II malocclusion. The mean pretreat-
power to detect a minimum difference of 0.86 points ment age was 13.13 6 2.21 years, the mean treatment
in the score of profile attractiveness, with a standard de- time (T2
T1) was 2.37 6 0.63 years, and the long-
viation of 0.8. The sample size calculation showed the term follow-up (T3
T2) was 34.19 6 5.17 years
need for 15 subjects per group.19 (Table I). The nonextraction (NE) group (NE group)
The retrospective sample was selected from files at comprised 16 subjects (10 females, 6 males). Six subjects
Bauru Dental School, University of S~ao Paulo, Bauru, presented Class I malocclusion, and 10 presented Class II
SP, Brazil, according to the following inclusion criteria: malocclusions. The mean T1 age was 13.21 6 0.83
(1) Class I or II malocclusions at the beginning of ortho- years, the mean treatment time (T2
T1) was 1.86 6
dontic treatment; (2) treatment protocol of nonextrac- 0.83 years, and the mean long-term follow-up evalua-
tion or with the extraction of 4 first premolars; (3) tion time (T3
T2) was 35.25 6 6.11 years (Table I).
complete orthodontic treatment with maxillary and The lateral cephalograms of the subjects were digi-
mandibular fixed edgewise appliance (0.022 3 0.028- tized. The dentoskeletal and soft-tissue cephalometric
in slot); (4) all permanent teeth up to the first molars landmarks were performed using Dolphin Imaging soft-
erupted before the beginning of treatment; (5) no tooth ware (version 11.5; Dolphin Imaging and Management
agenesis or anomalies; and (6) maxillary removable Solutions, Chatsworth, Calif). The tracings obtained

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Bravo Vallejo et al 3

Fig. Steps to make a black silhouette of the patient’s profile.

were standardized with the Frankfort plane horizontally from 1 (least attractive profile) to 10 (most attractive
oriented.24 profile).26 The evaluator could modify the scores before
The images were converted in black and white and submitting the form.
clipped using the Photoshop CC software (version To evaluate the precision of the evaluators, 2 profile
19.1.6; Adobe Systems, San Jose, Calif) (Fig). The clipped silhouettes were randomly repeated throughout the ques-
standardization was superiorly 1 cm above the glabella tionnaire, and the intraclass correlation coefficient was
point, anteriorly 1 cm from the tip of the nose, inferiorly used. The intraclass correlation coefficient of the preci-
2 cm below the throat point, and posteriorly through the sion of the evaluators in rating the profile attractiveness
condylion point.19,25 was 0.92, indicating an excellent intrarater agreement.27
All silhouettes were randomized by Microsoft Excel
software (Microsoft, Redmond, Wash). A questionnaire Statistical analyses
was created on Google Forms (Google LLC, Mountain The normal distribution of all quantitative variables
View, Calif). Questions about education level, age, and was evaluated using Shapiro-Wilk tests. Intergroup
profile silhouettes were inserted. The volunteers were comparability of sex distribution and type of malocclu-
invited to participate by the WhatsApp messaging appli- sion were performed with chi-square tests, and the pre-
cation (Meta Platforms, Menlo Park, Calif), and all sub- treatment; posttreatment; and long-term posttreatment
jects signed informed consent forms. ages, treatment time, time of long-term posttreatment
The evaluator sample size calculation was performed evaluation, and retention time were compared by inde-
to detect a difference of 0.7 points on a scale of 1-10, pendent t tests. In the intragroup comparison of pre-
with a standard deviation of 1.28 points,19 an a signif- treatment, posttreatment, and long-term
icance level of 5%, a b of 20%, and a test power of posttreatment stages, the repeated measures analysis
80%. The sample size calculation indicated the need of variance and Tukey tests were used. For comparison
for a minimum of 53 subjects in each evaluator group. of the profile attractiveness in the long-term among
The volunteers were divided into 3 groups according the groups treated with extraction and nonextraction
to education degree. Laypeople comprised 72 subjects was used independent t test, and a comparison of the
(43 females and 29 males) with a mean age of 33.40 score of profile attractiveness given by laypeople, den-
years. Dentists included 63 subjects (40 females and tists, and orthodontists at T1, T2, and T3, in both was
23 males) with a mean age of 30.24 years. Orthodontists performed with 1-way analysis of variance and Tukey
comprised 65 subjects (36 females and 29 males) with a tests. All tests were performed using the software Statis-
mean age of 33.58 years. The laypeople were defined as tica (version 12.0; StatSoft, Tulsa, Okla), and results were
persons without formal education in dentistry or dental considered significant for P \0.05.
hygiene; the dentists were specialists with formal educa-
tion; and the orthodontists were dental surgeons with
RESULTS
completed graduate degrees in orthodontics.
The evaluators were blinded to the groups and stages The groups were comparable regarding pretreatment,
of each profile evaluated. Profile attractiveness was rated posttreatment, and long-term posttreatment ages, time
on a 10-point numerical rating scale (NRS), ranging of long-term posttreatment evaluation and retention

American Journal of Orthodontics and Dentofacial Orthopedics - 2023  Vol -  Issue -

4 Bravo Vallejo et al

Table II. Intragroup comparison of the score of profile Table III. Comparison of the profile attractiveness in
attractiveness among the pretreatment, posttreat- the long-term among the groups treated with extrac-
ment, and long-term posttreatment stages (repeated tion and nonextraction (independent t test)
measures ANOVA and Tukey tests)
Profile P
Profile attractiveness E group (n 5 24) NE group (n 5 16) values
attractiveness T1 T2 T3 P value T1 3.46 6 1.41 3.43 6 1.38 0.947
E group 3.46 6 2.44a 4.07 6 2.50b 3.11 6 2.10c \0.001* T2 4.07 6 1.39 4.09 6 1.42 0.965
NE group 3.43 6 2.36a 4.09 6 2.46b 3.26 6 2.16c \0.001* T3 3.11 6 1.25 3.26 6 1.29 0.716

Note. Values are presented as mean 6 standard deviation. Different Note. Values are presented as mean 6 standard deviation.
superscripted letters (a,b, and c) in the same row indicate the pres-
ence of a statistically significant difference among the groups indi-
cated by the Tukey test.
ANOVA, analysis of variance. Table IV. Comparison of the age and sex distribution
*Statistically significant for P \0.05. among the 3 groups of evaluators (laypeople, dentists,
and orthodontists)
Laypeople Dentists (n 5 Orthodontists P
time, sex distribution, and type of malocclusion (Table I). Variables (n 5 72) 63) (n 5 65) value
The E group presented a greater treatment time than Age (y) 33.40 6 12.77 30.24 6 6.63 33.58 6 8.39 0.094z
that of the NE group (Table I). Sexy 0.646§
Both groups significantly improved the profile attrac- Females 43 40 36
tiveness with treatment and a statistically significant Males 29 23 29
decrease in the long-term posttreatment follow-up Note. Values are presented as mean 6 standard deviation.
y 2
(Table II). This long-term decrease made the profile c 5 0.88; degrees of freedom 5 2; zOne-way analysis of variance;
§
Chi-square test.
attractiveness scores even less than the pretreatment
scores in both groups (Table II).
At the pretreatment, posttreatment, and long-term
Table V. Comparison of the score of profile attractive-
posttreatment stages, the E and NE groups presented
ness given by laypeople, dentists, and orthodontists at
similar profile attractiveness (Table III).
T1, T2, and T3 in both groups (1-way ANOVA and Tu-
The groups of evaluators were comparable regarding
key tests)
age and sex distribution (Table IV).
The laypeople and dentists were more critical, giving Laypeople (n 5 Dentists (n 5 Orthodontists
lower scores of profile attractiveness for both groups in Group 72) 63) (n 5 65) P value
all 3 stages evaluated than were the orthodontists E
T1 3.37 6 2.49a 3.16 6 2.42a 3.86 6 2.35b \0.001*
(Table V).
T2 3.84 6 2.49a 3.70 6 2.51a 4.68 6 2.38b \0.001*
T3 2.86 6 2.01a 2.79 6 2.01a 3.71 6 2.15b \0.001*
DISCUSSION NE
T1 3.25 6 2.26a 3.16 6 2.35a 3.90 6 2.40b \0.001*
The assessment of profile attractiveness through sil-
T2 3.73 6 2.36a 3.81 6 2.49a 4.75 6 2.42b \0.001*
houettes has been identified as a reliable method to T3 3.03 6 2.09a 3.00 6 2.14a 3.77 6 2.17b \0.001*
assess the global perception of attractiveness.18,19 The
Note. Values are presented as mean 6 standard deviation. Different
standardization of the head position aligned with the superscripted letters (a,b, and c) in the same row indicate the pres-
Frankfort plane aimed to eliminate confounding fac- ence of a statistically significant difference among the groups indi-
tors.24 Silhouettes with a black profile on a white back- cated by the Tukey test.
ground allow for an effective attractiveness assessment, ANOVA, analysis of variance.
*Statistically significant for P \0.05.
removing confounding factors such as gender, age, skin,
hair, tattoos, and eye color.4,19,28
Randomizing the profile silhouettes prevents evalua-
tors from identifying variations in treatment types and slightly preferred as it is easy to complete.29 This method-
patient ages. The evaluators could also look at the images ology for evaluating facial silhouettes was previously used
and review their scores as often as they wanted, if neces- in several studies, and, in addition to being subjective, it is
sary, without time restrictions.19 Assessments by the NRS considered dependable and reproducible.30-32
method do not have great differences in practical use Pretreatment, posttreatment, and long-term post-
compared with other scales, such as the visual analog treatment ages, time of long-term posttreatment evalua-
scale and the Likert scale.29 The NRS appears to be tion and retention time, sex distribution, and type of

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Bravo Vallejo et al 5

malocclusion were comparable in both groups. In the NE type of treatment, malocclusion, and greater knowledge
group, the treatment time was shorter than in the E about facial profiles and knows the difficulty of treating
group, corroborating previous study findings.33-35 The these malocclusions.42,44,45
duration of orthodontic treatment is affected by One limitation of this study was that only facial profile
variables such as whether 1 or both arches are treated, silhouettes were evaluated because it is a 2-dimensional
the number of treatment phases, and not only the study. It would be suggested that future profile attractive-
extraction decision.33 It is possible that the increased ness studies be conducted with a 3-dimensional analysis
time in patients with extraction is due to more complex that would yield even more reliable results. Future studies
mechanotherapy. with other orthodontic mechanics are necessary to pro-
The evaluators detected a significant improvement in vide answers on how attractive these profiles appear
the profile’s attractiveness from the pretreatment and over the years after orthodontic treatment.
posttreatment stages in the E and NE groups and a sta-
tistically significant decrease in the long-term follow-up CONCLUSIONS
(Table II). This supports previous research that evaluated
1. There was a significant improvement in profile
profile silhouettes before and after treating patients with
attractiveness with treatment and a statistically sig-
Class II malocclusion, showing that evaluators perceive
nificant decrease in the long-term posttreatment
the profiles as more attractive after treatment.36,37 This
follow-up in both groups.
decrease in long-term profile attractiveness could be
2. At the long-term posttreatment follow-up, the pro-
due to the age of the E (49.56 years) and NE (50.32 years)
file attractiveness was similar in patients treated
groups, which has been shown to decrease profile attrac-
tiveness over the years.38-40 with and without extractions.
3. Laypeople and dentists were more critical, giving
Profile attractiveness in the pretreatment and post-
lower profile attractiveness scores for both groups
treatment stages of the E and NE groups were similar
in the 3 stages evaluated, than orthodontists.
(Table III). This similarity among the groups could be
because if teeth extraction is based on correct diagnostic
criteria, it will not harm the facial profile.16 AUTHOR CREDIT STATEMENT
At long-term posttreatment follow-up, the E and NE
Gabriel Bravo Vallejo contributed to data collection,
groups had statistically similar profile attractiveness original manuscript preparation, formal analysis, and
(Table III). This was similar to those found in other studies
manuscript review and editing; Gabriela de Dom^enico
that evaluated long-term posttreatment profile attrac-
Alcaraz Ros contributed to original manuscript prepara-
tiveness. After 15 years, the E and NE groups had statis-
tion and manuscript review and editing; Renan Morais
tically similar facial esthetics.18,19 One study showed that
Peloso contributed to manuscript review and editing;
in subjects treated with extractions of 4 premolars and
Caroline Martins Gambardela-Tkacz contributed to
without treatment after 25 years, there were no signifi-
data collection, investigation, and data curation; Paula
cant differences in the soft-tissue profile, in which they
Patricia Cotrin da Silva contributed to data collection,
presented an aging trend for lower and anterior high- investigation, data curation and manuscript review and
lighting.23 One study compared orthodontically treated
editing; Karina Maria Salvatore Freitas contributed to
and untreated subjects and identified growth in posterior
data curation and manuscript review and editing; and
and anteroinferior facial height in late adolescence.22
Marcos Roberto de Freitas contributed to manuscript re-
The groups of evaluators were comparable in terms
view and editing and supervision.
of distribution by age and sex (Table IV). Laypeople
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