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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 58-65

Rickett’s and Holdaway analysis following extraction of four premolars and orthodontic treatment in bimaxillary protrusion female Malays


Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia

Date of Submission12-Jun-2019
Date of Decision21-Sep-2019
Date of Acceptance04-Oct-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Prof. Rozita Hassan
Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian.
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_155_19

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  Abstract 

Aim: To quantify the amount of soft-tissue changes in Malaysian female patients treated with the extraction of first four premolars. Materials and Methods: This is a retrospective study involving 24 Malaysian female patients age between 18 and 24 years treated with extraction of the upper and lower first premolars and bonded by 0.22 × 0.28′′ standard edgewise technique. The average of treatment time was 22 months. Pre and posttreatment lateral cephalograms of patients were traced on a cephalometric tracing software CASSOS (Soft Enable Technology Limited, Hong Kong). Linear and angular measurements were made. Data were analyzed using paired t-test to determine the difference between two means. Results: All linear and angular measurements of hard- and soft-tissue changes showed significant differences except L1 to A-pogonion (A-pog) angle (P = 0.05), and the mean change has decreased to almost 1.0mm posttreatment. The Pearson’s correlation test showed that the lower lip contacts both the upper and lower incisors; hence, the lower lip position would be impacted not only by the lower incisor retraction but also by the upper incisor retraction. Conclusion: In Malaysian females, significant changes were found in soft-tissue profile post-orthodontic treatment with corresponding simultaneous change in the underlying hard tissue.

Keywords: Bimaxillary Protrusion, E-Line, H-Line, Premolar Extraction, Orthodontic Treatment


How to cite this article:
Ul Huqh MZ, Hassan R, Zainal Abidin SB, Karobari MI, Yaqoob MA. Rickett’s and Holdaway analysis following extraction of four premolars and orthodontic treatment in bimaxillary protrusion female Malays. J Int Oral Health 2020;12:58-65

How to cite this URL:
Ul Huqh MZ, Hassan R, Zainal Abidin SB, Karobari MI, Yaqoob MA. Rickett’s and Holdaway analysis following extraction of four premolars and orthodontic treatment in bimaxillary protrusion female Malays. J Int Oral Health [serial online] 2020 [cited 2020 Apr 3];12:58-65. Available from: http://www.jioh.org/text.asp?2020/12/1/58/279213




  Introduction Top


Facial esthetics is affected by the position of base hard and overlying soft tissue.[1] The treatment involving extraction of teeth versus non-extraction has been a matter of debate, as these can impact the patient’s profile and aesthetics. Hence, it is crucial for orthodontists to learn the effect of various treatment options.[2],[3]

The principle objective of the orthodontic treatment is to enhance facial aesthetics and maintain labial profile of the upper and lower lips.[4] The definite association between the changes in the hard and soft tissues in extraction cases is still questionable. A few authors have reported a high level of association between the position of upper incisor and lip retraction, advocating a nearby correlation between soft tissue and the underlying hard tissue.[5],[6],[7] However, other studies have suggested that a distinct corresponding change in the soft tissue certainly does not accompany changes in the dentition.[8],[9],[10]

Cephalometric measurement for various ethnic and racial groups has been described by many authors. Normal measurements for one ethnic group should not be considered as normal to other ethnic group.[11] These norms significantly vary, and therefore most of the cephalometric standards for each major ethnicity have been established.[12],[13]

Bimaxillary protrusion (BMP)––a condition characterized by protrusive maxillary and mandibular jaws with proclined incisors and an increased procumbency of the lips and facial convexity––is seen in many ethnic groups, especially African-American and Asian population.[14] A previous study carried out on Arabs and Moroccans also showed higher tendency toward BMP.[15],[16]

In many cultures, the negative impression of BMP with protruding lips and overlying protrusion of dentition affects many patients to seek orthodontic treatment to reduce this procumbence. To accomplish this objective, extraction of four premolars was planned to create space for retraction of the upper and lower anteriors.[10],[17] Many studies have been conducted on posttreatment soft-tissue changes, particularly in Class II malocclusions. Very little consideration has been given on the effect of the facial profile of Class I BMP Malay ethnicity post-orthodontic treatment.[18] Hence, this study was undertaken to quantify the amount of soft-tissue changes following the extraction of four premolars.


  Materials and Methods Top


This is a pre–post retrospective study. The purposive sampling technique was selected for the study. The sample size calculation was performed by the PS software version 3.1.2 with power 0.8 using paired t-test. The study sample comprised a pre and posttreatment lateral cephalometric record of 24 Class I BMP women aged between 18 and 24 years (mean age 20 + 6) . Patients were treated by single orthodontist at Specialist Orthodontic Clinic at School of Dental Sciences, Universiti Sains Malaysia, Health Campus Kelantan, Malaysia. The duration of the study was 24 months. The study sample was selected based on the inclusion and exclusion criteria. The inclusion criteria for the sample were as follows: (1) Malay females with Class 1 BMP, (2) four premolars extracted before orthodontic treatment, and (3) mild-to-moderate crowding. The cases which were indicated for orthognathic surgery has been excluded from the study.

All the patients were treated using preadjusted 0.022′′ slot edgewise appliance MBT-3M Unitek (Monrovia, California-US) and with maximum anchorage mechanics. After leveling an alignment, retraction was carried out using rubber power chain for 22 months.


  Cephalometric Analysis Top


All the pre and posttreatment lateral cephalometric radiographs were taken from the Planmeca ProMax® 3D (Helsinki, Finland) imaging device in a standard position by the trained radiographic technician. Subjects were asked to sit in natural head position with Frankfort Horizontal plane parallel to the floor with lips in relaxed position and teeth in maximum intercuspation. The lateral cephalometric radiographs were traced on a cephalometric tracing software CASSOS (Soft Enable Technology Limited, Hong Kong). Pre and posttreatment lateral cephalometric radiographs were traced at the same time to minimize the tracing error.[19] The anatomic landmarks on cephalometric film are shown in [Figure 1]. The description of each standard landmark is shown in [Table 1].
Figure 1: Landmark on the profile cephalometric films

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,
Table 1: Description of the standard landmarks used

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As per Rickett’s (1961), both pre-and-posttreatment measurements of soft tissue landmarks which are located posterior to the E-line and Sn-Pog line were recorded as negatives and the landmarks which are located anterior to the E-line and Sn-Pog line were recorded as positives. According to Holdaway, Ss depth was recorded as positive when the Ss point was located to the left of the line tangent to Ls and perpendicular to FH, whereas Ss depth was recorded as negative when the Ss point was located to the right of such lines [Figure 2] and [Figure 3].[20]
Figure 2: Pretreatment Rickett’s analysis report generated using CASSOS

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,
Figure 3: Posttreatment Rickett’s analysis report generated using CASSOS

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In addition, the distances from Ss and Si to the H-line were recorded as positive when the Ss point was located to the left of this line, whereas the distances from Li located to the left of the H-line were recorded as negative, and to the right of H-lines as positive [Figure 4] and [Figure 5].[21]
Figure 4: Pretreatment Holdaway analysis report generated using CASSOS

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,
Figure 5: Posttreatment Holdaway analysis report generated using CASSOS

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To determine the Intra-reliability measurement, Five lateral cephalometric radiographs (20%) were selected randomly and traced twice by a single investigator within a two-week time interval. The intraclass correlation coefficient was used to assess the degree of agreement, and these are shown with 95% confidence interval. The correlation analyses performed between the first and second measurements consistently showed coefficients >0.90.


  Statistical Analysis Top


The analyses were performed using the Statistical Package for the Social Sciences software version 24 (IBM) and the paired t-test. The value of P < 0.05 was considered statistically significant and the level of significance was 95%. A descriptive statistic was performed to calculate the mean and standard deviation of each variable. A Pearson’s correlation coefficient (r) was calculated to determine the correlation between hard and soft tissues.


  Results Top


Comparison between pre and posttreatment cephalometric measurements based on Holdaway’s

The pre and posttreatment values of Malaysian females showed statistically significant differences in all the variables [Table 2]. Mean and standard deviation were evaluated using the paired t-test. Significant differences were observed in nose prominence, Lower lip to H-line and Inferior sulcus to H-line.
Table 2: Pre and posttreatment cephalometric measurements based on Holdaway

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Comparison between pre and posttreatment cephalometric measurements based on Rickett’s

The comparison between the mean of pre and posttreatment values of Rickett’s analysis revealed significant differences with all variables except L1– A-pogonion (A-pog) angle. The descriptive statistics of Rickett’s variables for 24 subjects are shown in [Table 3].
Table 3: Pre and posttreatment cephalometric measurements based on Rickett’s

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Posttreatment correlation between hard- and soft-tissue changes

The Pearson’s correlation coefficient was used to calculate the ratio between U1 to A-pog and upper lip to E-plane, L1 to A-pog and lower lip to E-plane, U1–L1 and superior sulcus depth, U1–L1 and subnasale to H-line, U1–L1 and H-line angle, and U1–L1 and inferior sulcus to H-line. A value of P ˂ 0.01 is considered statistically significant. The significant correlations were obtained between U1–L1 and superior sulcus depth, U1–L1 and subnasale to H-line, and U1–L1 and H-line angle [Table 4].
Table 4: Pearson’s correlation between hard- and soft-tissue changes

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  Discussion Top


In this study, the soft-tissue facial angle (P = 0.000) and skeletal profile convexity (P = 0.000) are highly significant. This is in agreement with the study conducted on Pakistani female population by Syed et al.[22] However, their study had a limited sample size and included the younger age patients. The potential source of bias was reduced by two different observers by evaluating the same variables at different time intervals and found 90% agreement between two observers by Cohen’s κ score, showing a strong agreement between the observers.

Nose prominence is considered to be a recognizable characteristic of the face. Its significance would affect the treatment planning as it impacts the appearance of peripheral orofacial structures. The nose prominence in Malay females was lower than that in Malay males.[23] Saudis had significant reduction in nose prominence as compared with Turkish and Japanese.[24] In our study, post-extraction of four premolars with orthodontic treatment leads to upper incisor retraction with concomitant reduction in the lip procumbency that relatively decreases the prominence of the nose.

Significant differences were observed in superior sulcus depth which was increased slightly after treatment. This can be associated with increased lip prominence as reflected by the measurement subnasale to H-line but this increase is not considered as statistically significant which has similar findings shown by Albarakati and Bindayel.[24] Lower lip to H-line was increased because more retraction of the upper lip occurred than the lower lip, similar result has been reported by Amirabadi et al.[25] The inferior sulcus to H-line and soft-tissue chin thickness were increased slightly leading to reduction in upper lip sulcus depth, which were all highly significant. The inferior sulcus to H-line and soft-tissue chin thickness were increased significantly. Reduction in upper lip sulcus depth was noted after the treatment. These findings cannot be comparable with other studies due to limited number of studies in the literature. The similar has been reported by Sundareswaran and Vijayan.[26]

Rickett’s analysis was performed, and lower lip to E-line was reduced significantly (P = 0.000) indicating a reduction in lower lip protrusion. Any variations in values due to sexual dimorphism were ousted by selecting homogenized sample comprising women only. The difference in two sexes with regard to lip thickness indicates that the treatment outcome of extraction cases of the facial profile will be more remarkable in female patients than male patients. This occurred because women’s lips do not thicken with age but for males flattening of the face will occur as the age advances. Hence, any treatment by extraction for females with straight-to-convex profiles should be taken into consideration more cautiously.[27] In BMP, the lower lip mostly contacts both lower and upper incisors. Hence, the lower lip position would be not only influenced by the lower incisor retraction but also by the upper incisor retraction. This finding is supported by Syed et al.[1] In our study, no significant difference was observed in lower incisor to A-pog angle, which indicates that cephalometric norms of malay females are differ from the values of other ethnic groups. These distinct values of cephalometric measurements are specific for different ethnic groups similar has been reported by Bascifti et al.[11] Facial axis is more useful in determining the facial height and direction of growth of the face, which is raised significantly giving rise to favorable growth pattern. The facial axis and maxillary convexity are taken into account that the retraction of both upper and lower incisors achieved with treatment.[28] The upper lip to E-line response was slightly lower than the lower lip. This finding was slightly different from the findings of Sharma.[29] The difference could be because of variation in cephalometric norms for different ethnicities and also the method of treatment performed in which the authors have used 0.022 × 0.028′′ Roth preadjusted device after the extraction of four premolars.

Patients with BMP usually have good occlusion. They require treatment mainly because of protrusive profile and to provide better facial aesthetics. The clinical importance of this study is that the incisors must be positioned in the most aesthetic position by uprighting in the beginning followed by some bodily movement later. Therefore, it is necessary to maintain the position of the roots and retraction of incisors in this kind of malocclusion. Labial movement of the roots increases the maxillary convexity because of the movement of skeletal points in the forward direction, which can be a factor for undesirable results.[29],[30]


  Pearson’s Correlation Top


In this study, the lower lip to E-line was reduced significantly (P ˂ 0.01) with the simultaneous reduction in L1 to A-pog (r = 0.545). In other words, for every 1mm of lower incisor retraction, the lower lip retracted approximately to 0.5mm. Both the upper and lower incisors (U1–L1) were retracted significantly (P ˂ 0.01) with the concomitant reduction in super sulcus depth (r = –0.558) and subnasale to H-line (r = –0.520), which indicates that when upper lip retracts the lower lip retracts to the same extent with the subsequent retraction of underlying hard tissue. This finding is in agreement with previous studies.[26],[31],[32] In BMP, it has been suggested that the lower lip contacts both upper and lower incisors, and hence the lower lip position would be impacted not only by the lower incisor retraction but also by the upper incisor retraction.[1],[26] This study was carried out in one centre, so results might not represent the generalization of Malaysian population. In future, multicentered study is required to the generalization of the results.


  Conclusion Top


The following conclusions can be drawn from this study:

  • Extraction of first four premolars followed by posttreatment retraction of incisors leads to the adequate changes in soft tissue with the underlying hard tissue, thereby reducing the procumbence of the lips.


  • A positive correlation exists between upper and lower incisor retraction with favorable reduction in thickness of lower lip. Furthermore, the lower lip position would be affected not only by the lower incisor retraction but also by the upper incisor retraction.


  • In Malaysian females, significant changes in soft-tissue profile have been occurred post-orthodontic treatment with corresponding simultaneous change in underlying hard tissue. Further investigations with large sample size will be required to assess the soft-tissue profile following premolar extraction in order to assess the improvement in facial aesthetics.


  • Ethical policy and institutional review board statement

    The study was approved by the Institutional Review Board of Jawatankuasa Etika Penyelidikan Manusia (JEPeM), the Human Research Ethical Committee of Universiti Sains Malaysia, Kubang kerian- Kelantan, Malaysia on September 18, 2017 [USMKK/PPP/JEPeM[213.3 (15)].

    Acknowledgement

    We would like to thank Orthodontic Unit, School of Dental Sciences, University Sains Malaysia, Kubang kerian, Kelantan-Malaysia.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Khurshid SZ, Qazi SN, Zargar NM. Soft tissue changes associated with first premolar extractions in Kashmir female population. J Orofacial Res 2015;5:18-21.  Back to cited text no. 1
        
    2.
    Ozawa TO, Reis LLS, Kato RM, Rocha DL, Sathler R, Garib DG. Facial and nasolabial aesthetics of complete UCLP submitted to 2-stage palate repair with vomer flap. Cleft Palate Craniofacial J 2018;55:1211-7.  Back to cited text no. 2
        
    3.
    Sridharan S, Kumar SA. Effect of premolar extractions on vertical dimension in borderline extraction case: A retrospective study. Drug Invent Today. 2019 Feb 1;11.  Back to cited text no. 3
        
    4.
    Tadic N, Woods MG. Incisal and soft tissue effects of maxillary premolar extraction in class II treatment. Angle Orthod 2007;77:808-16.  Back to cited text no. 4
        
    5.
    Alkadhi RM, Finkelman MD, Trotman CA, Kanavakis G. The role of lip thickness in upper lip response to sagittal change of incisor position. Orthod Craniofacial Res 2019;22:53-7.  Back to cited text no. 5
        
    6.
    Manasa, R, Vinod P, Silju M. Effect of first premolar extraction on nasal airway dimension in adult bimaxillary dento-alveolar protrusion patients: A retrospective cephalometric study. Int J Curr Res 2018; 10:66478-82.  Back to cited text no. 6
        
    7.
    Xu TM, Liu Y, Yang MZ, Huang W. Comparison of extraction versus nonextraction orthodontic treatment outcomes for borderline Chinese patients. Am J Orthod Dentofacial Orthop 2006;129:672-7.  Back to cited text no. 7
        
    8.
    Hodgkinson D, Firth FA, Farella M. Effect of incisor retraction on facial aesthetics. J Orthod 2019;46:49-53.  Back to cited text no. 8
        
    9.
    Şahbaz EB, Cesur E, Altuğ AT, Ergül KC, Karasu HA, Memikoğlu UT. Is it possible to protract the maxilla by surgically assisted rapid maxillary expansion and intermaxillary class III elastics? Turk J Orthod 2019;32:96-104.  Back to cited text no. 9
        
    10.
    Leonardi R, Annunziata A, Licciardello V, Barbato E. Soft tissue changes following the extraction of premolars in nongrowing patients with bimaxillary protrusion: A systematic review. Angle Orthod 2010;80:211-6.  Back to cited text no. 10
        
    11.
    Basciftci FA, Uysal T, Buyukerkmen A. Craniofacial structure of Anatolian Turkish adults with normal occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop 2004;125:366-72.  Back to cited text no. 11
        
    12.
    Hwang HS, Kim WS, McNamara JA Jr. Ethnic differences in the soft tissue profile of Korean and European-American adults with normal occlusions and well-balanced faces. Angle Orthod 2002;72:72-80.  Back to cited text no. 12
        
    13.
    Shimizu Y, Arx JDV, Ustrell JM, Ono T. Comparison of cephalometric variables between adult Spanish and Japanese women with class I malocclusion. J Orthod Sci 2018;7:19.  Back to cited text no. 13
        
    14.
    Bills DA, Handelman CS, BeGole EA. Bimaxillary dentoalveolar protrusion: traits and orthodontic correction. Angle Orthod 2005;75:333-9.  Back to cited text no. 14
        
    15.
    Lahlou K, Bahoum A, Makhoukhi MB, Aalloula el H. Comparison of dentoalveolar protrusion values in moroccans and other populations. Eur J Orthod 2010;32:430-4.  Back to cited text no. 15
        
    16.
    Hussein E, Abu Mois M. Bimaxillary protrusion in the Palestinian population. Angle Orthod 2007;77:817-20.  Back to cited text no. 16
        
    17.
    Kusnoto J, Kusnoto H. The effect of anterior tooth retraction on lip position of orthodontically treated adult Indonesians. Am J Orthod Dentofacial Orthop 2001;120:304-7.  Back to cited text no. 17
        
    18.
    Konstantonis D. The impact of extraction vs nonextraction treatment on soft tissue changes in class I borderline malocclusions. Angle Orthod 2012;82:209-17.  Back to cited text no. 18
        
    19.
    Leea TS, Khamisb MF, Albajalanb OB, Mokhtarc N. The assessment of accuracy and reproducibility of cephalometric analyses using computer-assisted simulation system for orthognathic surgery (CASSOS) software. Arch Orofacial Sci 2012;7:75-84.  Back to cited text no. 19
        
    20.
    Chalipa J, Roochi MM, Mortazavi M, Borujeni ES, Sarmadi S, Khodabakhshi M, et al. Cephalometric evaluation of facial soft tissue changes after orthodontics and bimaxillary orthognathic surgery treatment in patients with skeletal Class III discrepancy. Iran J Orthod 2018;13.  Back to cited text no. 20
        
    21.
    Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod 1983;84:1-28.  Back to cited text no. 21
        
    22.
    Shafi AM, Khan FN, Khan AG, Nadeem M, Khursheed T, Jehan S et al. A soft tissue cephalometric analysis for Pakistani adult using Holdaway’s analysis. Int Med J 2018;25:51-3.  Back to cited text no. 22
        
    23.
    Purmal K, Alam MK, Zam NMZ. Cephalometric norms of Malaysian adult Chinese. Int Med J 2013;20:87-91.  Back to cited text no. 23
        
    24.
    Albarakati SF, Bindayel NA. Holdaway soft tissue cephalometric standards for Saudi adults. King Saud Univ J Dent Sci 2012;3:27-32.  Back to cited text no. 24
        
    25.
    Amirabadi GE, Mirzaie M, Kushki SM, Olyaee P. Cephalometric evaluation of soft tissue changes after extraction of upper first premolars in class ΙΙ div 1 patients. J Clin Exp Dent 2014;6:e539-45.  Back to cited text no. 25
        
    26.
    Sundareswaran S, Vijayan R. Profile changes following orthodontic treatment of class I bimaxillary protrusion in adult patients of Dravidian ethnicity: A prospective study. Indian J Dent Res 2017;28:530-7.  Back to cited text no. 26
    [PUBMED]  [Full text]  
    27.
    Sharma P, Arora A, Valiathan A. Age changes of jaws and soft tissue profile. Sci World J 2014;7.  Back to cited text no. 27
        
    28.
    Omar Z, Short L, Banting DW, Saltaji H. Profile changes following extraction orthodontic treatment: A comparison of first versus second premolar extraction. Int Orthod 2018;16:91-104.  Back to cited text no. 28
        
    29.
    Sharma JN. Skeletal and soft tissue point A and B changes following orthodontic treatment of Nepalese class I bimaxillary protrusive patients. Angle Orthod 2010;80:91-6.  Back to cited text no. 29
        
    30.
    Pupulim DC, Henriques JFC, Janson G, Henriques FP, Freitas KMS, Garib D. Comparison of dentoskeletal and soft tissue effects of class II malocclusion treatment with Jones Jig appliance and with maxillary first premolar extractions. Dent Press J Orthod 2019;24:56-65.  Back to cited text no. 30
        
    31.
    Dallel I, Megdiche A, Ghedira Y, Tobji S, Amor AB. Do orthodontic extractions have an impact on the cutaneous profile? J Dentofacial Anomalies Orthod 2018;21:506.  Back to cited text no. 31
        
    32.
    Windyasari O, Yusuf M. The effect of upper incisor anteroposterior position changes on the lip profile in Class I malocclusion. International Dental Conference of Sumatera Utara; 2017 (IDCSU 2017) 2018 Feb 7. Atlantis Press.  Back to cited text no. 32
        


        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4]



     

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