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Excellence in Orthodontics
Excellence in Orthodontics
Chapter
4
Treatment Planning: the Face
Nigel Harradine
50 TREATMENT PLANNING: THE FACE
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Introduction
This chapter addresses the role that facial appearance plays in orthodontic treatment planning. This chiefly involves
profile planning, but the anterior facial view and overall concepts of facial appearance also require consideration.
Orthodontics chiefly influences facial appearance through its potential effect on lip prominence, but orthognathic
surgery or effective orthopaedic mechanics can change all aspects of the facial shape and proportion. We therefore
need to explore the evidence about the importance, the assessment and the potential for therapeutic change of
facial appearance.
• survival
o feeding
• socialisation
o communication
• self-fulfilment
o acting and singing
Much of the fashion in facial appearance is related to a wish to preserve or re-create youthfulness. The youthful
human face is characterised by a large forehead, large eyes, a foreshortened lower face and full lips. Why the
preoccupation with youthfulness? Almost certainly because of its associations with fertility.
Evolutionary psychology ….
• facial cosmetic surgery procedures performed on female patients have increased 35% since 1997
• one of the most common procedures is the injection or insertion of foreign material into the lips to
increase their fullness
• men have evolved a preference for younger women thus narrowing the range of mates to those
young enough to bear children
• as women's reproductive capacities drop off, so do men's ratings of attractiveness for them, even if
they are shown only pictures of women's faces
Although we may believe that beauty is in the eye of the beholder, the evidence points in the other direction. Iliffe
(1960) published 12 photographs of young women aged 20-25 years, representing different facial types
photographed under the same conditions, in an English newspaper. Readers were asked to rank the photographs
in order of attractiveness or ‘prettiness’. Each response was correlated as to the age, sex and occupation of the
respondent and 4,300 replies were obtained. The positive correlations obtained were high and significant,
suggesting that in the United Kingdom a common basis for judging facial attractiveness existed and that it was
shared by both men and women regardless of age.
The same study, with 100,000 responses, was repeated in the United States of America by Udry (1965) who found
that not only was there significant agreement as to whom the most attractive facial appearance belonged, but that
the top three selections were the same in both Great Britain and the United States of America. After the first three
selections, the order differed only slightly.
In a study by Xu et al (2008) study, the agreement and disagreement between pairs of Chinese and US orthodontists
in ranking the facial attractiveness of end-of-treatment photographs of growing Chinese and white orthodontic
patients was determined. Each orthodontist independently ranked standard clinical sets of profile, frontal, and
frontal-smiling photographs of 43 white patients and 48 Chinese patients. The resulting correlations ranged from
+0.004 to +0.96 with a median of +0.54. Of these, 18.7% were lower than 0.4; 41.0% were lower than 0.5; 68.8% were
lower than 0.6; 91.6% were lower than 0.7; and only 8.4% were greater than 0.7. As had been anticipated,
correlations between judges were higher when they ranked patients of their own ethnicity than when they ranked
patients of different ethnicity, but the differences were smaller than had been expected. The rankings of no pair of
judges correlated negatively. The distribution of levels of agreement between pairs of orthodontists did not differ
substantially according to whether the pairings were from the same or different continents although judges from
the same continent had better agreement when judging patients from that continent. This study again
demonstrates consistency in the evaluation of facial attractiveness, across many countries, genders and races.
facial distances were not related to attractiveness and that most of the facial ratios were different from the golden
ratio. The golden ratio has not been shown to be a useful guide to facial aesthetics.
Racial studies
Interestingly, a similar study was undertaken by Martin (1964) to determine how males judged female beauty
according to racial group membership. A panel of judges were asked to rank ten photographs of black females
from the least Negroid (most Caucasian) to the most Negroid. Three groups of men (50 American whites, 50
American blacks and 50 African (Nigerian) blacks) were then asked to rank the photographs by facial attractiveness.
The results support the proposition that American whites and American blacks share a common aesthetic standard
for female facial attractiveness – that of the Caucasian facial model. The African blacks rated Caucasian features less
often attractive than did either American whites or American blacks. This indicates the effect of social context on
the preference of racial groups.
Frontal analysis
This is essentially the measurement of facial asymmetry. This is not a frequent problem to an extent which is clinically
significant. With the interpupillary line as a horizontal, the middle of the philtrum is usually recommended as the
best midline vertical reference line. Meyer-Marcotty et al (2011) assessed the three dimensional perception of facial
asymmetry. The identification of asymmetry in virtual 3D faces was independent of the profession of the raters -
orthodontists, oral and maxillofacial surgeons and lay people. Lay people were able to detect asymmetries when
located near the midline of 3D faces. Asymmetries of the nose were judged as more negative than asymmetries of
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the same degree of the chin. The location and architecture of the nose play a crucial role in perception of symmetry.
Surprisingly, the authors detected a left/right bias of facial asymmetry. A deviation of the nose to the left led to
more negative rating of facial perception, whereas a deviation of the chin to the right was judged more negatively.
Profile analysis
Although a completely lateral view of the head is not common in social contact, quantitative analysis of an oblique
view is not very practicable and in practice, an analysis of the profile is a very useful clinical tool.
Madsen et al (2008) also investigated the relationship between familiar cephalometric planes and TH. Interestingly,
they found that on average the palatal plane is parallel to TH; so palatal plane is on average an acceptable substitute
for TH, but once again varies more in relation to TH than the random error of TH (2 degrees in this study). Bansal et
al (2012) also found that palatal plane (ANS-PNS) and TH are on average parallel, with a standard deviation for palatal
plane of 4 degrees and a range of 18 degrees for males and 15 degrees for males, so TH will be a better reference
plane in the more outlying instances of palatal plane orientation.
The reproducibility of TH was explored in three dimensions and over time in a more recent study (Weber et al 2013).
Using a rather ingenious but uncomplicated methodology they assessed the reproducibility in the sagittal, coronal
and axial planes of space with 3-dimensional imaging. Natural head position was found to be reproducible in all
three planes of space. The coronal plane had the least variation over time, followed by the axial and sagittal planes.
Most recently, Tian et al (2015) measured the reproducibility of three different methods of obtaining natural head
posture and found that all three had very good reproducibility in both pitch and roll. TH seems a robust plane of
reference.
Analyses in relation to TH frequently include measures of the relative prominence of features to a true vertical at
right angles to TH. This is a well-known part of profile assessment. Opinions vary as to the most aesthetic profile
when assessed in this linear method. Arnett and McLaughlin (2004) suggest the use of a vertical line (True Vertical
Line - TVL) through subnasale. It is probable that no single anteroposterior placement suits every malocclusion and
for example in cases of maxillary retrusion, Arnett and McLaughlin suggest moving the TVL 1 to 3 mms anteriorly.
It may be helpful to know that Bansal et al (2012) found in a large sample of class 1 occlusions and “acceptable
profiles” that nasion–pogonion was on average at right angles to TH for both males and females. Some
cephalometric computer programs such as OPAL, which is produced on behalf of the British Orthodontic Society,
contain the option to record in natural head posture and therefore have anteroposterior measurements which refer
to a true vertical.
A relatively straightforward and interesting analysis for assessing soft tissue balance has been proposed by Bass
(2003). The anteroposterior positions of the lips and chin are assessed in relation to a perpendicular from subnasale.
This analysis disregards the nose. An appealing aspect in principle is the use of a natural vertical obtained from
posing during a lateral photograph, which is then transferred to the cephalometric x-ray. This uses a simple
protractor and Ricketts E line as a reference common to photograph and cephalogram.
54 TREATMENT PLANNING: THE FACE
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Figure 4.1: The nasolabial angle (NLA). This is a well - Figure 4.2: A suggested alternative to NLA. The lip
established aesthetic indicator, but may not be the best guide to inclination relative to the horizontal
aesthetics of the upper lip profile
Key point: Natural head posture is a valid, reproducible and easily obtained position and plane of reference. It
should be given stronger consideration for aesthetic assessment of the profile.
Lip prominence
Lip prominence is the aspect of profile most frequently influenced by orthodontic treatment and two important
parameters to assess are the prominence of the lips relative to the nose and chin (assessed via the lower lip to
Ricketts E line distance or using Merrifield’s line) and the nasolabial angle (NLA). These have their limitations but
are also quick and easy to apply and therefore stand a good chance of being incorporated in routine orthodontic
diagnosis. One of the limitations of the NLA (Figure 4.1) is that it comprises both the angle of the lower surface of
the nose and also the inclination of the upper lip and facial aesthetics in profile may be more influenced by the latter
component which is also influenced by orthodontic treatment than the nasal component. An angle between a
tangent to the upper lip and the facial horizontal (Figure 4.2) might be a better measure of the aesthetics of upper
lip profile but is not in common use and the NLA with intelligent interpretation may therefore be preferred.
Ricketts E (aesthetic) line which joins the tip of the nose to the chin is very easy to visualise and to use and these are
strong points in its favour. The Holdaway angle (Figure 4.3) is another well-known measure of balance in facial
profile. It has been used in the British Orthodontic Society national audit of successively treated orthognathic cases
(Johnston et al 2006), and is now officially recommended by the BOS clinical effectiveness committee as one of
seven cephalometric measures to audit the outcome of orthognathic cases. OPAL, which is produced on behalf of
the British Orthodontic Society, was used to measure and extract the data and the Holdaway angle is included in
the OPAL analysis. This angle is open to a little confusion both from differences in definition and also depending
on whether the correction factor for the skeletal convexity is applied. The original papers (Holdaway 1983,
Holdaway 1984) are recommended and fully explain his thoughts with plenty of examples. The norm is entirely his
opinion. A paper by Basciftci et al (2003) used this angle and is a good example of the angle in action as a measure
of balance in facial profile. The angle in its conventional definition is between soft tissue nasion-soft pogonion and
soft pogonion-labrale superius. The larger the facial convexity (i.e. the more skeletal class 2), the larger the angle
should be, according to Holdaway. Interestingly, both the Turkish dental students in this paper and the Bolton
norms have Holdaway angles at the very upper end of ‘normal’ according to Holdaway. OPAL gives both the
uncorrected value and the value corrected for convexity according to Holdaway’s formula. An important point
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about Merrifield’s line and the Holdaway angle are that they do not
include nose prominence in the assessment of facial balance
whereas the Rickett’s E line does. It will be recalled that Ricketts
fully appreciated that the nose continues to grow anteriorly for
several years beyond the cessation of growth in stature. We should
have the probable final size of the nose in mind when we consider
lip prominence as one of the factors in our treatment plan.
• does it produce results that are stable to a smaller or greater extent than other positions?
• does it help achieve a good facial appearance?
• does it facilitate a good occlusion?
• can the planned position be more easily achieved than other alternatives?
• is the planned incisor position conducive to long-term dental health?
following six months when no appliances were in place. Stucki and Ingervall (1998) found that on average 70% of
the proclination produced by Jasper Jumpers subsequently relapsed.
Sims and Springate (1995) investigated more modest A-P alterations in lower incisor position and found a similar
tendency for incisors moved labially during treatment to return towards their starting position, but found that
modest retroclination of incisors was stable or even increased post-retention. This is one of several hints in the
literature that invasion of the space previously occupied by the tongue is more stable than invasion of lip or cheek
space. Unhelpfully, we more frequently wish to expand arches rather than contract them. These authors also
commented on the wide standard deviation of post-treatment change around the average changes.
A study by Williams and Andersen (1995) investigated the very interesting idea that lower incisor proclination might
prove to be stable in those patients in whom the mandible is expected to develop in an anterior rotational pattern
according to the morphological features described by Bjork. The treatment would in effect be taking advantage of
the natural tendency for lower incisors to compensate by proclining as the mandible rotates anteriorly. The authors
found an average proclination during treatment of 9 degrees with an average relapse of 3.4 degrees and an average
treatment change relative to APo of 2.7 mm with an average relapse of 1.2 mm. The degree of relapse was very
significantly related to the amount of labial movement or proclination although some cases were a marked
exception to the general rule. Disappointingly, anterior rotators are no more likely to permit stable lower incisor
proclination than other groups.
This paper therefore supports the previous studies, but can similarly be interpreted in two ways:
or alternatively
Both these statements are true, but many clinicians seem to recall only one or the other of them. Several details of
the study by Williams and Anderson are worth noting. Firstly, all cases were retained until skeletal maturity (hand-
wrist radiographs) - an average of 3.3 years. Secondly, the post-retention Little’s index was much better than most
of those reported by Little (1990) (2.8 mm vs. 4.7 mm). Was this due to the retention until cessation of growth or is
it related to the anterior growth rotation? Thirdly, the relapse in lower incisor labial movement was not related to
the relapse in Little’s index, which again proved hard to statistically attribute to any parameter other than expansion
during treatment of the intercanine width. Finally we should note that not all of those predicted to rotate anteriorly,
actually did. Also, marked pogonial growth made some cases appear to have no linear movement of the lower
incisors in spite of definite proclination relative to the mandibular plane. An interesting paper!
Key point: Stability of anteroposterior incisor change is not statistically related to stability of irregularity. “Stability”
can mean different things.
Paquette et al (1992) also found that cases which had been treated with an average of 2.8 mm more lower incisor
proclination than another matched group of cases, finished with slightly greater irregularity (Little’s index) out of
retention. The difference in post-treatment relapse of irregularity between the two groups was very small (0.6 mm),
but the findings did suggest that labial movement of lower incisors during treatment does, on average, increase the
chance of subsequent relapse.
No study has demonstrated consistent anteroposterior stability in a group of orthodontic cases in which the lower
incisors have been significantly changed in their A-P position during treatment. Reviewing knowledge on the ability
of the soft tissues to adapt to lower arch expansion, Ackerman and Proffit (1997) proposed an approximate limit of
2 mm for labial movement of the lower incisors if anteroposterior stability is the main factor influencing our decision.
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It is of interest to detour for a moment and note % of cases with > 2mm crowding
that Artun et al (1990) found that substantial 25 yrs+
(>10 degrees) proclination of lower incisors was Treatment Pre - treatment
post-treatment
not associated with greater subsequent relapse Maxilla Non-extraction 8% 15%
than a group treated without proclination.
No treatment 4% 6%
However, these were severe Class 3 patients Extraction 16% 0%
who, subsequent to lower incisor proclination,
Mandible Non-extraction 3% 28%
had a backward mandibular sagittal split
No treatment 9% 16%
osteotomy; i.e. if the soft tissue environment is
Extraction 16% 11%
radically changed by surgical repositioning of
the jaw, the usual soft tissue effects do not Table 4.1: Jonsson and Magnusson (2010) long term changes in
seem to apply. crowding. Percentages of cases with > 2mm crowding
An interesting suggestion is the one formally advocated by Selwyn-Barnett (1996) who points out that in effect the
lips cannot ‘know’ which incisor is touching them and that we can therefore procline the lower incisor in class 2
division ii cases to touch the lower lip at the same A-P position as was occupied before treatment by the extruded
upper incisor. The stability of the results of such a philosophy has not been well tested, but the resulting plan is
often required in any case to achieve occlusal goals (Andrews’ keys 3 and 6) and is a useful way of structuring a plan
to procline the lower incisors in such cases, as well as a sensible hypothesis about stability. However, Canut and
Arias (1999) found that proclining lower incisors in class 2 division ii cases leads to much more relapse of arch
irregularity than when the arch length was not increased. This is salutary evidence that a plausible hypothesis may
be incorrect. We aim to retain with particular care Class 2 division 2 cases in which we have substantially proclined
the lower incisors and with increasing emphasis on informed consent, prior information about the need for and
importance of retention is especially relevant in these cases.
An impressive long-term study by Jonsson and Magnusson (2010) over 25 years found that treatments involving
extractions produced much less relapse of crowding in both arches when compared with non-extraction cases,
particularly in the lower arch (Table 4.1). Cephalometrics was not included in this study but it is probable that non-
extraction cases involved relative labial movement of the incisors.
Key point: Studies of the stability of good modern treatment are almost impossible due to the practice of indefinite
retention.
movement of the upper lip when the upper incisors were retracted by an average of 5.0 mm – an average ratio of
28%. Large tooth movements are therefore required on average to produce clinically substantial soft tissue change,
but the variability is huge. In this paper, the range of upper lip anteroposterior change associated with upper incisor
retraction was 10.0 mm! Pancherz and Anehus-Pancherz (1993) reported that there was no correlation (r=0.02)
between the hard and the soft tissue changes brought about by treatment with the Herbst appliance. More recent
papers have continued to find poor correlation between incisor movement and change in the overlying lips.
Kusnoto and Kusnoto (2001) found a correlation coefficient of r=0.39 for the upper lip. In other words, the change
in incisor position accounted for r2 = 16% (i.e. very little) of the variation in lip change. The average ratio of
movement was 1:4 for lip: incisor change. A paper by Lai et al (2000) suffers from choices in cephalometric values,
which greatly lessen the potential usefulness of the results, but still reveals “a large variation in the soft tissue
response to dental movements”. The paper includes the result that two groups which differed in their change in
upper incisor inclination during treatment by an average of 20 degrees, differed in their change in upper lip to E line
distance by an average of only 0.5 mm. This large variation in soft tissue response was emphasised again in a more
recent study by Tadic et al (2007) which focused on predictors of change in lip shape and NLA with upper incisor
correction in class II cases. They found a large range of change in NLA (40 degrees) and no correlation with incisor
A-P change.
Key Point: Changes in anteroposterior incisor position clearly result in much smaller and highly variable changes
in the prominence and shape of the overlying lips. Prediction of changes in lip profile is prone to substantial error, but
in general lips will move less than we might either hope or fear from the viewpoint of profile aesthetics.
Since tooth alignment tends to deteriorate even if we put the teeth where stability is most probable:
• all cases should have indefinite retention and if this is the case, then why should the orthodontist be
concerned with minimising spontaneous relapse when all case are to be retained forever anyway?
Or alternatively
• for one reason or another few young patients wear retainers for the rest of their life and it is therefore
best practice to try to leave the lower incisors in a position that minimises the probability of relapse
when retention is discontinued.
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These two approaches are both philosophically entirely tenable. The chapter on Stability and Retention discusses
further the evidence about stability in general and the best practical approach to retention in the light of this
evidence.
The question of a suitable goal for lower incisor position is inextricably entwined with extraction choices and the
overall merits and disadvantages of extractions per se will be discussed in the chapter on the Extraction Non-
Extraction Debate. The only aspect which is pertinent in this chapter is the influence of extractions on the facial
profile.
Similarly, the studies by Luppanapornlap et al (1993) and by James (1998), both demonstrated that patients treated
with extractions had on average slightly more prominent lips at the end of treatment than those treated on a non-
extraction basis. This reflected the fact that initial lip prominence was a significant factor in the extraction/non-
extraction decision of the orthodontists planning that group of patients. Extractions were selected in patients who
initially had more prominent lips. A more recent study by Zierhut et al (2000) again showed the small extra lip
retraction with extractions (1.7 mm for the lower lip and 1.0 mm for the upper lip) when compared with non-
extraction cases, but since extractions had been chosen in cases with slightly more prominent lips, the final average
soft tissue profile was identical in both groups. Finally, the study by Shearn and Woods (2000) was notable for
showing the wide variety of anteroposterior changes in lower incisor position, which result for all combinations of
premolar extractions. This is simply a reflection of all the other variables in the treatment - notably the amount of
crowding, of class 2 elastics, of headgear and of differential growth. An opinion that extractions or non-extraction
are “good” or “bad” for the profile is clearly simplistic and uninformed.
Lay opinion
A good study by Bishara and Jakobsen (1997) involved assessment by lay people of profile changes in class 2 division
i malocclusions treated with and without extractions. Lay judges:
• preferred the profile of normals to the pre-treatment profile of Class 2 division i patients
• immediately after treatment, preferred the changes in profile in the extraction group to the changes
in the non-extraction group
• two years after treatment, showed no preference for the profiles of either treatment group or for the
untreated normal group
• considered the changes with treatment to be very favourable in both treatment groups.
Key point: All the published data strongly supports the view that orthodontic treatment with good planning and
execution produces changes in profile which are viewed favourably by the lay public whether or not extractions are involved.
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Differences in soft tissue appearance if the same case is treated extraction or non-extraction
Understandably, not many studies have succeeded in examining this. The study by Paquette et al (1992) gave some
extremely useful information for one type of malocclusion. The equivalent groups of cases assembled by the
equipoise discriminant analysis as being equally susceptible to extraction or non-extraction, were unsurprisingly,
mild to moderate class 2 division i malocclusions with mild lower arch crowding. The cases averaged 14.5 years
post-retention and were recalled and compared aesthetically, for mandibular dysfunction and for stability.
Cephalometric analysis of the long term results revealed that the extraction group had lower incisors averaging 2
mm more posterior than the non-extraction group and the lower lip was 1.2 mm further behind E line in the
extraction group. However, these measurable and statistically significant differences produced no detectable
aesthetic or stability effects. Regarding aesthetics, various assessments of the patients' opinion of the aesthetic
changes in their silhouettes and facial photographs both before and after treatment revealed no difference between
the groups. Regarding stability, the Little index in the lower labial segment at recall was 2.9 mm in the extraction
group and 3.4 mm in the non-extraction group. This difference was again not significant, although the overall
reduction in lower labial irregularity was slightly greater in the extraction group (by 1.9 mm.), which happened to be
slightly more crowded initially and relapsed fractionally less. It would seem that in such mildly crowded cases, if
they are treated using non-extraction mechanics which only produce mild labial movement of the lower incisors,
(average 0.4 mm in this group), it does not matter significantly whether the cases are treated with or without
extractions from the viewpoint of aesthetics or stability.
Twenty years later a very similar study has been reported by Konstantonis (2012). The same equipoise discriminant
analysis was used to compare extraction and non-extraction, this time in a sample of class 1 cases. Analysis showed
that the extraction decision was based on initial crowding, facial convexity and lower incisor protrusion. This
confirms that clinicians were basing their extraction decision on factors relating respectively to stability, facial
aesthetics and occlusal fit. Interestingly, the extraction rate in the parent sample was 30% which compared to 55%
for the sample treated in the 1970s from which Paquette derived his borderline group. In the derived borderline
sample of the Konstantonis study, extraction lead to an average of 2 mm greater retraction of the lower lip relative
to E line and an increase of 5 degrees in the NLA compared to no change for this angle in the non-extraction group.
The superimposed average profiles in that paper show that these differences have a small effect on the facial profile.
These two studies of borderline cases firmly indicate that if it is felt that treatment will be quicker, easier or more
pleasant if carried out on a non-extraction basis, then this would be the sensible approach in this type of case. The
studies did not investigate these latter aspects of speed and practicability, but it seems reasonable to propose that
if cases have modest space requirements, then we should not extract on grounds of profile or stability
However, the impressive long-term study by Jonsson and Magnusson (2010) of cases reviewed more than 25 years
after treatment, found that treatments involving extractions produced much less relapse of crowding of greater
than 2mm when compared with non-extraction cases, in both arches but particularly in the lower arch. Such a long-
term study is rare and for understandable reasons. The authors understandably conclude that non-extraction cases
should receive proportionately more rigorous long-term retention but these days, long-term retention is the advice
in almost all cases.
In his long-term studies of dental irregularity, Little (1990) identified “lower arch development in the mixed
dentition” (i.e. expansion and proclination of the labial segment) as the only treatment regimen to show significantly
worse results than others in this respect. Little (2002), again referred to this work in his paper contributing to the
section on early treatment which followed the American Association meeting on that subject. The core of his
conclusions was that whilst you can hold and use the Leeway space without any detriment to stability, lateral and
anterior expansion of the arches at an early age caused a degree of relapse which was “significant and alarming”
and this was for cases which only had to have mild proclination to be included in the “expansion” group. In contrast,
a paper by Ferris, Alexander, Boley and Buschang (2005), showed that patients with mild crowding but significant
irregularity, when treated in the late mixed dentition with RME, arch expansion, interdental stripping and without
extractions, had very acceptable stability more than 4 years out of retention. There was no availability of
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cephalometric data on incisor labiolingual movement, but the arch width measurements showed that a substantial
percentage of premolar expansion was stable in this age group. The effect of extraction choices on lateral stability
and smile aesthetics is considered in the chapter on Treatment Planning - the Smile
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American Journal of Orthodontics and Dentofacial Orthopaedics
134: 74-84