|Year : 2020 | Volume
| Issue : 1 | Page : 58-65
Rickett’s and Holdaway analysis following extraction of four premolars and orthodontic treatment in bimaxillary protrusion female Malays
Mohamed Z Ul Huqh, Rozita Hassan, Suhaila B Zainal Abidin, Mohmed IA Karobari, Muhammad A Yaqoob
Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
|Date of Submission||12-Jun-2019|
|Date of Decision||21-Sep-2019|
|Date of Acceptance||04-Oct-2019|
|Date of Web Publication||25-Feb-2020|
Prof. Rozita Hassan
Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian.
Source of Support: None, Conflict of Interest: None
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 2022 Jan 18];12:58-65. Available from: https://www.jioh.org/text.asp?2020/12/1/58/279213
| Introduction|| |
Facial esthetics is affected by the position of base hard and overlying soft tissue. 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.,
The principle objective of the orthodontic treatment is to enhance facial aesthetics and maintain labial profile of the upper and lower lips. 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.,, However, other studies have suggested that a distinct corresponding change in the soft tissue certainly does not accompany changes in the dentition.,,
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. These norms significantly vary, and therefore most of the cephalometric standards for each major ethnicity have been established.,
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. A previous study carried out on Arabs and Moroccans also showed higher tendency toward BMP.,
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., 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. Hence, this study was undertaken to quantify the amount of soft-tissue changes following the extraction of four premolars.
| Materials and Methods|| |
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|| |
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. The anatomic landmarks on cephalometric film are shown in [Figure 1]. The description of each standard landmark is shown in [Table 1].,
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].,
|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].,
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|| |
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|| |
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].
| Discussion|| |
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. 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. Saudis had significant reduction in nose prominence as compared with Turkish and Japanese. 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. 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. 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.
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. 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. 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. 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. The upper lip to E-line response was slightly lower than the lower lip. This finding was slightly different from the findings of Sharma. 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.,
| Pearson’s Correlation|| |
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.,, 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., 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|| |
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)].
We would like to thank Orthodontic Unit, School of Dental Sciences, University Sains Malaysia, Kubang kerian, Kelantan-Malaysia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]