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Scientific Dental Journal

Original Article

Lower Facial Height and Soft Tissue Changes 
in Bimaxillary Protrusion Cases  

Kasmawaricin1, Nurhayati Harahap2, Amalia Oeripto2

1 Postgraduate Program in Orthodontics, Faculty of Dentistry, University of North Sumatera – Indonesia
2 Department of Orthodontics, Faculty of Dentistry, University of North Sumatera – Indonesia

‘Corresponding Author: Kasmawaricin, Faculty of Dentistry, University of North Sumatera – Indonesia

Email: [email protected]
Received date: October 14, 2018. Accepted date: January 8, 2019. Published date: January 31, 2019.
Copyright: ©2019 Kasmawaricin, Harahap N, Oeripto A. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided
the original author and sources are credited.
DOI: http://dx.doi.org/10.26912/sdj.v3i1.3633

ABSTRACT

Background: Bimaxillary protrusion is frequently treated by extracting the four first premolars and retracting the incisor
with maximum anchorage. This treatment may result in soft tissue changes, particularly in lip retraction, lip thickness,
upper lip angle and nasolabial angle. However, the changes in facial height after orthodontic treatment often trigger
controversies. Objectives: To determine the effects of incisor retraction on lower facial height and soft tissue changes in
Class I malocclusion with bimaxillary protrusion treated by the extraction of the four first premolars. Methods: Pre-
treatment and post-treatment lateral cephalometric radiograph samples of 25 patients treated with the standard Edgewise
fixed appliance were collected. Each sample was traced and a reference line perpendicular to Sella-Nasion minus 7º
through the true vertical line (TVL) was established. Arnett analysis was applied to calculate incisor retraction, lower
facial height, lip retraction, lip thickness, upper lip angle and nasolabial angle changes. The results of the measurements
were statistically analyzed using a paired T-test and Pearson correlation. Results: No statistically significant changes
were found between upper incisor retraction and lower facial height (p > 0.05) and upper lip thickness (p > 0.05). The
same lower incisor retraction occurred with lower facial height (p > 0.05) and lower lip thickness (p > 0.05). Significant
positive correlation was found between upper incisor retraction and the changes in the upper lip retraction (r = 0.959, p <
0.05), upper lip angle (r = 0.775, p < 0.05) and nasolabial angle (r = 0.647, p < 0.05), while the lower incisor retraction
had a positive correlation with the changes in lower lip retraction (r = 0.902, p < 0.05). Conclusion: The extraction of the
four first premolars followed by the retraction of the incisor can cause changes in lip retraction, upper lip angle and
nasolabial angle but not in lower facial height and lip thickness.

Keywords: bimaxillary protrusion, incisor retraction, lower facial height, soft tissue changes

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Background
Orthodontic treatment aims to resolve dentoskeletal Cephalometric radiography is one of the ways to
problems and to achieve the ideal occlusion, functional measure facial aesthetics in orthodontic. With this
stability and facial and dental aesthetic harmony.1 radiography, many analyses can be used to evaluate lip
Individuals often complain about unpleasant facial position and soft tissue aesthetics, such as “E” (Ricketts),
aesthetics and search for orthodontic treatment that is “S” (Steiner) and “H” (Holdaway) lines, “Z” (Merrifield
intended to restore balance to the facial profile, especially Angle) and the True Vertical Line (TVL) by Arnett.8,9 The
in protrusion cases.2 Bimaxillary protrusion, or analysis put forward by Rickett, Steiner, Merrifield and
bimaxillary dentoalveolar protrusion, is defined as the Holdaway measure only the anteroposterior position from
proclination and protrusion of maxillary and mandibular the furthest forward points of the upper and lower lips to
anterior teeth with molar teeth in a Class I Angle the reference lines.10
relationship. Usually, this is indicated by an increase in the
Along with the development in the orthodontic field,
procumbency of the lips and a convex facial profile, where
Arnett proposed an analysis to measure facial balance as
the upper and lower lips are incompetent. Consequently,
well as diagnosis and treatment plans by combining
patients complain about the unpleasant aesthetic.3,4
clinical analysis for clinical facial analysis and hard tissue
Orthodontic treatment in bimaxillary protrusion cases and soft tissue cephalometric analysis (STCA).11 One of
includes retraction and retroclination of maxillary and the measurements for STCA is the TVL, which measures
mandibular teeth, which have an impact on the reduction the distance between anteroposterior soft tissue and the
of procumbency and convexity of the soft tissue. This can dentoskeletal structure, which is combined with the
be achieved through the extraction of the first four thickness of the soft tissue.8,9
premolar teeth and followed by retraction of the anterior
STCA is an analysis for facial soft tissue
teeth using a maximum anchorage mechanism.4 The effect
cephalometry that can be used to diagnose five different
of premolar teeth extraction to vertical facial height
facial areas that are related. Those areas include the
continues to be debated. With the extraction, facial sagittal
dentoskeletal structure, soft tissue structure, facial height,
and vertical dimensions change with the movement of the
TVL projection and facial harmony.8,11,12,13 An STCA
molar teeth. Several researchers have stated that the
value was obtained from a cephalogram acquired with the
coverage of molar teeth with a movement to mesial by
patient’s head in the natural position and with lips in a
extraction leads to the reduction of vertical dimensions
passive state.8
and mandibular angle. In contrast, a number of researchers
do not agree that teeth extraction leads to This study aimed to determine the effects of incisor
counterclockwise mandibular rotation and a decrease in retraction on lower facial height and soft tissue changes in
facial vertical dimensions.5 Class I malocclusion with bimaxillary protrusion using
TVL-STCA by Arnett at the Orthodontic Specialists
Moreover, the success of orthodontic treatment in
Clinic, University of Sumatera Utara.
bimaxillary protrusion cases that involve the extraction of
the first four premolar teeth followed by incisor retraction
causes changes in the soft tissue profile that are
Materials and Methods
beneficial, such as the movement of the posterior of the This retrospective study incorporated 25 samples
upper and lower lips to reduce lip procumbency and the (based on a minimum sample size calculation) of medical
increase of nasolabial and mentolabial angle.6 Sukhia records and lateral cephalometric radiographs of male and
reported that there were changes in the soft tissue profile female patients between 18 and 35 years of age with
and a reduction in lower facial height with the extraction malocclusion class I (ANB: 2º ± 2º) with bimaxillary
of the first four premolar teeth and the retraction of the protrusion (maxillary incisor proclination I:SN > 102º ± 2º
incisor in bimaxillary protrusion cases.7 and mandibular incisor proclination ī:MP > 90º ± 3º). The

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SCIENTIFIC DENTAL JOURNAL 01 (2019) 01-07

patients were treated with extraction of four premolar angle formed from nose base and ULA passing the Sn
teeth and orthodontic treatment using standard Edgewise point). The soft tissue structure is shown in Fig. 2.
0.018-in. brackets. All samples were collected randomly
The measuring was done twice by an operator, and an
by an operator at the Orthodontic Specialists Clinic,
intra-rater reliability test was performed. Further, a
University of North Sumatera.
Shapiro-Wilk test was conducted to see the normality of
The cephalometric radiographs consist of pre- and measurement. Pre- and post-treatment variables were
post- treatment. Each cephalometric radiograph was traced analyzed using a T-paired test. To see the correlation
and had reference lines drawn by dragging lines that between incisor retraction and lower facial height and soft
connect S (Sella) points with Na (Nasion) points. Then x- tissue, a Pearson correlation was used.
axis was determined through the S-NA line by forming a
7º angle downwards through the S point (SN minus 7º),
while the y-axis, which is the TVL, was determined
through the subnasale and perpendicular to the x-axis. The
changes in incisor retraction was measured from the TVL
projection from the Mx1 and Md1 points. There are the
distances measured from the TVL to the incisal edge of
the maxillary and mandibular incisor, respectively The
measurement for lower facial height is the space between
the soft tissue of the subnasale and the menton (Fig. 1).

The changes in soft tissue were measured by the

projection of the TVL and soft tissue structure. Each TVL
projection against ULA (upper lip anterior) and LLA
(lower lip anterior) was used to determine the extent of the
change in the upper and lower lips anteroposterior (Fig. 1).
The soft tissue structure includes upper lip thickness (the
distance from ULA to upper lip inside), lower lip
thickness (the distance from lower lip outside to the
inside), upper lip angle (the angle formed from ULA and
TVL that passes the Sn point) and nasolabial angle (the Figure 1. Reference lines and points used in this study.

Figure 2. Soft tissue structure.

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Result
This study was conducted at the Orthodontic facial soft tissue pre- and post- treatment are shown in
Specialists Clinic, University of Sumatera Utara, with 25 Table 1. Change is considered significant in all variables
cephalometry radiographs of patients between 18 and 35 with a p value of < 0.05. Table 2 shows the correlation
years of age (26.08 ± 4.67) with malocclusion Class I between the amount of incisor retractions and lower
(ANB: 2.46º ± 1.16º) with bimaxillary protrusion facial height and soft tissue in the Pearson correlation.
(maxillary incisor proclination I:SN 116.2º ± 4.56º and
Based on the results shown in table 2, no
mandibular incisor proclination ī:MP 105.14º ± 5.65º). Of
significance was found (p > 0.05) between the maxillary
the patients, 32% were male and 68% were female, and
incisor retraction and lower facial height and the upper
they were treated with four premolar teeth extraction and
lip thickness as well as mandibular incisor retraction with
orthodontic treatment using standard Edgewise 0.018-in.
lower facial height and lower lip thickness. A strong
brackets.
positive correlation (r = 0.8 – 1.0) is shown in maxillary
Samples measurements were done twice by an incisor retraction with upper lip anteroposterior position
operator. A consistency test using intra-rater reliability (r = 0.902). Moreover, a strong positive correlation is
shows that the first and second data are reliable or also found (r = 0.60 – 0.79) in maxillary incisor upper lip
consistent with Cronbach’s Alpha value of > 0.398. Thus, retraction with upper lip angle (r = 0.775) and nasolabial
data taken was from one of the measurements. The angle (r = 0.647).
Shapiro-Wilk normality tests shows that data was
Simple regression analysis shows that maxillary
distributed normally (p > 0.05).
incisor retraction at 1 mm caused 1.034 mm upper lip
The amount of maxillary and mandibular incisor retraction. Then, the retraction of the mandibular incisor
retraction and changes to the lower facial height and by 1 mm caused retraction of the lower lip by 0.132 mm.

Table 1. Measurement results of pre- and post-treatment

Pre-treatment Post-treatment Changes

Variable n p
Mean SD Mean SD Mean SD

Maxillary incisor distance (mm) -4.57 1.10 -10.11 1.29 -5.54 0.75 25 0.000*

Mandibular incisor distance (mm) -8.80 0.99 -12.78 1.28 -3.98 0.71 25 0.000*

Lower facial height (mm) 80.56 1.21 79.72 1.27 -0.83 0.59 25 0.000*

Upper lip distance (mm) 6.85 0.89 4.19 0.99 -2.65 0.44 25 0.000*

Lower lip distance (mm) 4.37 1.40 0.87 1.38 -3.50 0.53 25 0.000*

Upper lip thickness (mm) 13.83 0.60 14.11 0.66 0.28 0.28 25 0.000*

Lower lip thickness (mm) 12.14 0.68 12.69 0.82 0.54 0.25 25 0.000*

Upper lip angle (o) 23.36 2.27 14.84 2.49 -8.52 1.47 25 0.000*

Nasolabial angle (o) 88.12 2.57 96.72 2.71 8.60 1.38 25 0.000*

* Significant difference (p < 0.05)

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Table 2. The correlation between incisor retraction and lower facial height and soft tissue

Maxillary incisor Mandibular incisor

retraction retraction
Variable
r p r p

Lower facial height (mm) 0.144 0.491 0.018 0.931

Anteroposterior upper lip position (mm) 0.959* 0.000 0.424 0.035

Anteroposterior lower lip position (mm) 0.460 0.021 0.902* 0.000

Upper lip thickness (mm) 0.192 0.358 0.441 0.027

Lower lip thickness (mm) 0.404 0.045 0.268 0.194

Upper lip angle (o) 0.775* 0.000 0.480 0.015

Nasolabial angle (o) 0.647* 0.000 0.360 0.137

* Correlation significant at 0.000 level.

Discussion
Diagnosis and treatment planning are necessary for result shows no significant changes at TAFH (total
the successful treatment of malocclusions. However, anterior facial height) and LAFH (lower anterior facial
facial aesthetics do not only depend on hard tissue, as the height) variables.15
analysis alone is inadequate. This is a result of the various
thicknesses of soft tissue, the length of the lips and tissue Research done by Zafarmand states that premolar
posture.11,13 Cephalometry analysis of soft tissue is a teeth extraction (either four or two premolar teeth) to
method used to measure facial disharmony and identify reduce facial height does not provide significant changes
the cause of it. It can be stated this way: a good facial to the patients after treatment.14 Chua et al. studied the
aesthetic is achievable if the root problems can be effect of extraction and non-extraction to LAFH and
identified and treated.12 Among the analyses for soft while they reported a significant increase in the non-
tissue, Arnett analysis is a combination of hard and soft extraction group, there was no significant difference in
tissue used to evaluate upper, middle and lower facial the group with extraction.5,8,15 Cusimano, McLaughlin et
structures.11,13 al. did not find any difference in facial height in
hyperdivergent patients with first premolar extraction and
Orthodontic treatment by premolar extraction aims to wrote that an increase in vertical dimension along with
resolve tooth and arch size discrepancy to allow the growth and development that was caused by the
correction of anterior teeth inclination or to reduce facial extrusion during molar tooth movement to mesial.5,15
vertical height.14 Based on the results of this study,
premolar teeth extraction followed by incisor retraction at This study aligns with research done by Pearson and
either the maxillary or mandibular does not provide Schudy, who stated that the coverage of extraction space
significant statistical changes for the lower facial height. might be caused by the movement of molar tooth to
This result aligns with the study done by Ramesh in mesial. This results in the decrease in vertical dimension
which the changes in vertical height in a high-angle case and mandibular angle. A study by Isaacson and Ulgen
using premolar teeth extraction were measured. The reported that the movement of a molar tooth to mesial

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SCIENTIFIC DENTAL JOURNAL 01 (2019) 01-07

without extrusion causes mandibular anterior rotation. is, then the higher the rise of the nasolabial angle.7 The
Pearson stated that the movement of a posterior tooth to changes to the nasolabial angle reduce teeth procum-
mesial causes reduction in the SN/MP angle.5 bency.3

The major complaints of malocclusion in bimaxillary There are no changes in upper lip thickness from
protrusion are incisor tooth and lip protrusion.3 Kusnoto maxillary incisor retraction in this study, similarly with the
predicted the changes in soft tissue profile are achieved study done by Kojo et al. On the contrary, Kasai’s study
after orthodontic treatment, especially in cases of shows a relationship between incisor and lips thickness.17
malocclusion with bimaxillary protrusion.16 The treatment According to Kojo et al., the significant increase in upper
assumes that the upper and lower lips will move back, and lower lips thickness was based on a T-paired test. This
while the nasolabial angle will increase as a result of was not caused by the tension during the retraction.9 The
maxillary and mandibular incisor retraction. probability of lip thickness is from the relaxation of the lip
Consequently, the facial procumbency is reduced.5,16 muscles that occurs after incisor retraction. Moreover,
According to Lai et al. and Oliveira et al., there is a wide mandibular incisor retraction also causes a significant
variation of soft tissue response, and it is difficult to posterior movement of the lower lip with a ratio of
predict or correlate perfectly to alter tooth position.2 1:0.132. Study showed that the decrease of Md1 by 3.87
mm, with lower lip reduced by 3.46 mm and with a ratio
In this study, maxillary tooth incisor retraction causes
of 1.12:1 for mandibular incisor and lower lip retractions.9
significant changes in posterior movement of the upper
This study has no changes to lower lip thickness as a result
lip, decrease of the upper lip angle and increase of the
of mandibular incisor retraction.
nasolabial angle. This aligns with the research conducted
by Kocadereli, who stated that the retraction causes an
alteration in lip position and reduces facial convexity.8
Conclusion
Similarly, the study done by Khurshid et al. stated that the In the case of bimaxillary protrusion, orthodontic
extraction of the first four premolar teeth followed by treatment comprising the extraction of the first four
anterior retraction is able to reduce tooth and soft tissue premolar teeth causes movements to the posterior of lips, a
procumbency in the Kashmir population with bimaxillary decrease in the upper lip angle and an increase in the
protrusion.6 Next, a 1 mm maxillary incisor retraction will nasolabial angle. Therefore, the procumbency in the facial
produce a 1.034 mm retraction of the upper lip. This is profile is reduced.
similar to research by Yasutomi et al. that analyzed lateral
cephalometry radiograph pre- and post- treatment of 38 Acknowledgment
patients with Class I Angle bimaxillary protrusion treated
by extraction of the first four premolar teeth. The report The authors would like to thank the Orthodontic
shows the ratio of maxillary incisor retraction and upper Department, Faculty of Dentistry, University of North
lip retraction is 1.85:1.9 A study by Nanda shows Sumatera for their support for this study.
maxillary incisor retraction of 3.1 mm caused the upper lip
to move inward by 1.9 mm.8 Furthermore, research Conflict of Interest
conducted by Arumugam et al. shows maxillary incisor
retraction of 2.9 ± 2.8 mm has resulted in upper lip The authors declare that there are no conflicts of
retraction of 0.9 ± 1.7 mm with a ratio of 3:1, whereas interest.
mandibular incisor retraction of 1.6 ± 2.0 mm caused
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